Exploring the validity of routine individuated service data for antenatal HIV surveillance in the Western Cape

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Johnson, Samantha Brinkmann, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4065819/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Mar, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted 4 You are reading this latest preprint version Abstract Background In the Western Cape, South Africa, public-sector individual-level routine data are consolidated from multiple sources through the Provincial Health Data Centre (PHDC). This enables the description of temporal changes in population-wide antenatal HIV seroprevalence. We evaluated the validity of these data compared to aggregated program data and population-wide sentinel antenatal HIV seroprevalence surveys for the Western Cape province. Methods We conducted a retrospective cohort analysis of all pregnancies identified in the PHDC from January 2011 to December 2020. Evidence of antenatal and HIV care from electronic platforms were linked using a unique patient identifier. HIV prevalence estimates were triangulated and compared with available survey estimates and aggregated programmatic data from registers as recorded in the District Health Information System. Provincial, district-level and age-group HIV prevalence estimates were compared between data systems using correlation coefficients, absolute differences and trend analysis. Results Of the 977800 pregnancies ascertained, PHDC HIV prevalence estimates from 2011–2013 were widely disparate from aggregate and survey data (due to incomplete electronic data), whereas from 2014 onwards, estimates were within the 95% confidence interval of survey estimates, and closely correlated to aggregate data estimates (r = 0.8; p = 0.01), with an average prevalence difference of 0.4%. PHDC data show a slow but steady increase in provincial HIV prevalence from 16.7% in 2015 to 18.6% in 2020. The highest HIV prevalence was in the Cape Metro district (20.3%) Prevalence estimates by age group were comparable between sentinel surveys and PHDC from 2015 onwards, with prevalence estimates stable over time among younger age-groups (15–24 years) but increased among older age-groups (> 34 years). Conclusions This study compares sentinel seroprevalence surveys with both register-based aggregate data and consolidated individuated administrative data. We show that in this setting linked individuated data may be reliably used for HIV surveillance and provide more granular estimates with greater efficiency than seroprevalence surveys and register-based aggregate data. HIV surveillance sentinel surveys routine data HIV prevalence Figures Figure 1 Figure 2 Introduction Monitoring the progress of HIV programmes is reliant, in part, on robust surveillance. Whilst global HIV surveillance has evolved since the beginning of the epidemic( 1 , 2 ), survey-based approaches remain the mainstay in many settings. Since 1990, the National Antenatal Sentinel HIV Survey has been conducted among pregnant women at selected public health antenatal clinics in all nine provinces of South Africa annually or biennially( 3 – 5 ). Until 2015, the surveys were limited to women presenting for their first antenatal visit, but since then follow-up antenatal visits have also been included( 3 , 6 , 7 ). Due to the national antenatal survey being underpowered to provide accurate estimates at district and sub-district level, the Western Cape Provincial Department of Health expanded the national survey to additional sites from 2001 to 2015 to generate more accurate sub-provincial estimates( 4 ). In 2013, WHO and UNAIDS published Guiding principles on ethical issues in HIV surveillance indicating that unlinked anonymous testing should only be used where there is demonstrable inadequacy of program data for surveillance purposes( 8 ). The WHO 2015 C onsolidated guidelines on HIV testing services , and the WHO 2022 Consolidated guidelines on person-centred HIV strategic information , recommend moving towards using routine programmatic data for antenatal HIV surveillance( 8 – 10 ). To facilitate this transition in surveillance strategy, evaluations of routine data are required. A 2020 assessment of the national prevention-of-mother-to child programme concluded that South Africa was close to achieving the transition to routine data surveillance in relation to HIV testing, but that further evaluation of data completeness and accuracy was required( 11 , 12 ). While these studies look specifically at the validity of routine HIV testing data in comparison to laboratory-based HIV testing data from surveys, it should be emphasised that HIV patient management in South Africa is based on routine HIV point-of-care testing results. Reassuringly, available literature shows high antenatal HIV testing coverage in South Africa of up to 98% by 2011( 13 ). Use of routine data for surveillance purposes requires further validation with other surveillance data sources. In the Western Cape province of South Africa there are two routine programmatic health information systems related to maternal and HIV care. Aggregated provincial data captured from service-based registers are housed in the District Health Information System (DHIS)( 14 ). The HIV testing services register comprises 46 reporting elements (manual and calculated) for key HIV indicators. The Western Cape Provincial Government has additionally developed a Provincial Health Data Centre (PHDC) in which all individual-level routine data captured electronically in the province are consolidated on a single platform, leveraging the patient folder number as the unique patient identifier( 14 , 15 ). This allows linkage of various information systems, including laboratory, pharmacy, and patient administration data, providing a rich source of individuated health information, in the absence of routine electronic patient health records. Within this environment, disease-specific patient cascades (virtual cohorts), such as the HIV care cascade and maternity cascade, may be developed using specific markers of care at different points( 14 ). Several studies in low- and middle-income countries have compared antenatal survey estimates with routine HIV data( 8 , 16 – 21 ). A 2013 study in the Western Cape showed comparable estimates between antenatal survey data and aggregated antenatal HIV data, but also reported disparities at the sub-district level( 4 ). To date there have been no studies in the South African context comparing antenatal survey HIV estimates with individuated routine data estimates. We sought to evaluate the validity of routine HIV prevalence estimates in pregnant women in the Western Cape Province of South Africa as compared to sentinel surveillance. Methods The study was set in the Western Cape province of South Africa, which is comprised of one metropolitan district, Cape Metro and five less urbanised districts (Overberg, Garden Route, Central Karoo, West Coast and Cape Winelands). We compared cross-sectional HIV antenatal survey estimates to those derived from aggregated program data and individuated program data 2011 to 2020. To evaluate the validity of routine HIV prevalence estimates in pregnant women we analysed four datasets; these are described below. National antenatal survey data National sentinel antenatal survey HIV prevalence estimates for the Western Cape province were obtained from the South African National Department of Health. District-level and age-disaggregated estimates were provided on all pregnant women attending their first antenatal visit in a public health facility in the Western Cape during a 6-week survey period in the years 2011–2015. Post 2015, the national antenatal survey was conducted biennially. In years 2015, 2017 and 2019, the national survey data included pregnant women attending first antenatal visits or follow-up antenatal visits in a public health facility during a 6-week period. However, to promote consistency with earlier surveys, we limit our estimates to first antenatal visit. Blood specimens of survey participants were tested for HIV at a central laboratory using HIV ELISA tests. Expanded provincial antenatal survey data Provincial sentinel antenatal survey data 2011–2015 (subsequently discontinued), incorporating larger, proportionally weighted sample sizes, were obtained from the Western Cape Department of Health. To attain provincial estimates, sub-district data were weighted using the proportional distribution of antenatal first visits in the prior year. DHIS (Routine aggregated HIV program data) Aggregated program data included all women attending their first antenatal visit at primary health care facilities in the Western Cape 2011–2020. All women, regardless of HIV status, are offered a point-of-care HIV test at first antenatal visit. Results of these tests are captured in facility-based registers, initially prevention-of-mother-to-child transmission (PMTCT) register and later primary health care services register. As PMTCT register data were limited from 2011–2013, provincial estimates from 2011 and 2012 were obtained from a study comparing routine aggregated data to sentinel surveys( 4 ). From 2014 to 2020, the proportion of pregnant women at first visit with evidence of prior HIV diagnosis or new diagnosis, derived from the primary health care services register, was used to calculate prevalence estimates. “HIV positive PMTCT initial test” and “Known HIV positive client” elements were combined as the numerator, with total “Antenatal first visit” as the denominator. Routine HIV testing is based on a point-of-care HIV testing algorithm conducted by an HIV counsellor or nurse, where only discordant test results are confirmed by central laboratory-based ELISA testing. Known HIV positive status is captured by an HIV counsellor or nurse based on self-reported HIV and medical records confirming HIV diagnosis. PHDC (Routine individuated HIV program data) A retrospective cohort was derived from the PHDC which included de-identified linked data of all pregnant women attending public health facilities across the province 2011–2020. The cohort was enumerated using the PHDC maternity cascade which links electronic records of all patients with administrative or laboratory evidence indicative of pregnancy. Pregnancies inferred with high confidence were included, as they have at least one high confidence evidence such as a rhesus antibody test (conducted routinely at first antenatal visit), pregnancy test, International Classification of Diseases (ICD) Tenth Revision code indicating pregnancy or pregnancy outcome, maternal discharge summary or repeat moderate confidence evidences such as antenatal visits. Since information specific to the first visit is not routinely captured in all public health facilities, it was not possible to distinguish between first and follow-up antenatal visits, however all pregnancies were only captured once. District and sub-district for pregnancy was determined by the geographic location of the facility of first pregnancy evidence. The pregnancy period was estimated using the pregnancy outcome date and/or any available evidence on gestational age, with year allocated according to the date of first record of pregnancy. Since HIV diagnosis is based on point-of-care testing, these results are not digitised and therefore not available to the PHDC. In the absence of these testing data, administrative, laboratory and pharmacy evidence of HIV diagnosis before or during the estimated pregnancy period was used to determine antenatal HIV status of women in the maternity cohort. The proportion of pregnancies with electronic evidence of HIV diagnosis prior to pregnancy or during pregnancy amongst all pregnant women was used to calculate antenatal HIV prevalence estimates. Analysis Data were analysed using Microsoft Excel and Stata 17 (Stata Corporation, College Station, Texas, USA). Measures of central tendency and dispersion were used to describe continuous variables, depending on distribution. Categorical variables were described using proportions and 95% confidence intervals, using the normal approximation to the binomial distribution. Descriptive characteristics of the PHDC cohort (2014–2020) were validated with 2014 provincial antenatal survey data. Prevalence estimates from provincial surveys, and aggregated and individuated program data, were calculated for comparison with national survey estimates, serving as the gold standard in this comparative analysis. Data were analysed by year at provincial and district level for comparison. Provincial estimates from all datasets were further compared with provincial antenatal HIV prevalence estimates from the Thembisa mathematical model( 22 ). This is an integrated demographic and HIV model for South Africa, calibrated to a number of HIV data sources including antenatal HIV prevalence surveys( 22 ). Quantitative comparisons were analysed using correlation coefficients and average percentage differences. Individuated data from 2015 onwards were further disaggregated by district and age for prevalence estimates. Provincial age-group estimates were compared between PHDC and the national antenatal survey from 2015. There were no comparators available for district-level age group estimates as the national antenatal survey is underpowered for this purpose. Data were categorised using age categories routinely used in antenatal survey reporting. The DHIS estimates (2011–2020) and survey estimates (2011–2015) are limited to pregnancies registered for antenatal care, whereas PHDC estimates (2011–2020) include all pregnancies. Ethical considerations The study was approved by the University of Cape Town Human Research Ethics Committee (HREC 083/2021) and the Western Cape Provincial Health Research Committee. All antenatal HIV sentinel survey and DHIS data were received as aggregates. Data from the PHDC were de-identified before release for the study according to the Western Cape Department of Health Data Access Policy Guidelines. Results From 1 January 2011 to 31 December 2020, 977 800 and 989 568 pregnancies were enumerated by the PHDC and DHIS, respectively. Table 1 presents study population size per year compared with sample sizes of both provincial and national antenatal surveys. As compared to the DHIS, fewer pregnancies were enumerated by PHDC prior to 2015. Amongst women presenting for their first antenatal visit as recorded in the DHIS aggregated data, the percentage known to be living with HIV increased from 9.5% (95% CI 9.4–9.7%) in 2014 to 15.0% (95% CI 14.8–15.2%) in 2020. Over the same period, the percentage of women accepting an HIV test at first antenatal visit declined from 90.4% (95% CI 90.2–90.6%) to 81.0% (95% CI 80.8–81.2) (Table 1 ). The characteristics of the women participating in the PHDC cohort (2014–2020) and the 2014 antenatal survey (unweighted) are shown in Table 2 . As seen in Table 1 and Fig. 1 , PHDC HIV prevalence estimates from 2014 onwards are closely aligned to national, provincial and DHIS data. Table 1: Antenatal HIV prevalence estimates by dataset Pregnancies (N) HIV testing (DHIS) HIV prevalence § National Survey Provincial Survey DHIS PHDC DHIS/PHDC difference Known HIV positive among all first antenatal visits (%) Accepted testing among all first antenatal visits (%) National Survey (%, 95% CI) Provincial Survey (%, 95% CI) DHIS (%) PHDC (%) 2011 4044 9812 97588 46703 -50885 18.2 14.3 - 22.8 18.4 17.7 - 19.2 18.4‡ 11.1 2012 4010 8711 97144 59826 -37318 16.9 13.8 - 20.5 17.8 16.7 - 18.3 18.7‡ 12.3 2013 3793 8125 96993 81761 -15232 18.7 15.1 - 23.0 17.1 16.4 - 18.0 14.0 2014 4036 7480 99454 94200 -5254 9.5 89.7 18.7 15.7 - 22.3 18.6 17.7 - 19.4 15.0 15.9 2015 7517† 7560 92168 101730 9562 9.8 90.1 18.9 16.4 - 21.7 17.6 16.8 - 18.4 15.6 16.7 2016 90034 106256 16222 11.8 90.4 17.0 17.0 2017 3571 95334 115704 20370 15.1 89.2 18.0* 16.5 – 19.7 19.3 18.2 2018 101044 120547 19503 14.6 84.7 18.2 18.1 2019 3943 110145 123907 13762 14.3 82.6 18.8** 17.1 – 20.5 17.4 18.5 2020 109664 127166 17502 15.0 81.0 17.6 18.6 †2015 national survey included additional Western Cape data and was limited to women presenting for first antenatal visit. ‡2011 and 2012 DHIS estimates denominator was total number of women refusing or accepting PMTCT initial tests whereas later estimates used the denominator of total antenatal visits *Prevalence estimate is among first antenatal visit only. 2017 reported prevalence including both first and follow-up attendees is 15.9% (95% CI 14.2 -17.8). **Prevalence estimate is among first antenatal visits only. 2019 reported prevalence including both first and follow-up attendees is 17.9% (95% CI 16.2 – 19.7). §95% Confidence intervals are not reported for routine data estimates as the whole population is included precluding the need for sampling Table 2 Descriptive characteristics of PHDC Cohort (2014–2020) compared to 2014 Provincial Antenatal Survey PHDC Cohort 2014–2020 (n = 789510) Percentage 95% CI Antenatal survey 2014 (n = 7526) Percentage 95% CI Electronic evidence of current and prior pregnancy* Gravidity 1 57.9 57.8–58.0 30.4 29.4–31.5 2 28.0 27.9–28.1 32.0 30.9–33.0 3 10.2 10.2–10.3 21.7 20.8–22.7 4 2.9 2.9–3.0 10.1 9.5–10.8 5 or more 0.9 0.9–1.0 5.8 5.3–6.3 Age (median; IQR) 27.0 (22.6–32.0) 26.4 (22.0–31.0) Age Category < 15 0.5 0.4–0.5 0.4 0.3–0.6 15–19 11.8 11.7–11.9 13.5 12.7–14.2 20–24 26.4 26.3–26.5 28.5 27.5–29.5 25–29 27.3 27.2–27.4 26.9 25.9–27.9 30–34 20.5 20.4–20.6 19.8 18.9–20.8 35–39 10.6 10.5–10.6 8.6 8.0–9.3 > 39 3.0 3.0–3.1 2.2 1.8–2.5 District** Cape Winelands 13.7 13.7–13.8 15.8 15.0–16.7 Central Karoo 0.97 0.95–1.0 1.9 1.3–1.9 Cape Metro 67.4 67.3–67.5 52.9 51.8–54.1 Garden Route 9.0 8.9–9.0 15.0 14.2–15.8 Overberg 3.6 3.5–3.6 5.5 5.0–6.0 West Coast 4.6 4.5–4.6 9.1 8.5–9.8 No district recorded 0.7 0.7–0.8 *Gravidity estimates (number of times a woman has been pregnant, including current pregnancy) in the PHDC are not reliable since historic data are incomplete. Electronic evidence of current and prior pregnancy is used as a proxy to provide a full description of the cohort. **Unweighted The average difference in antenatal HIV prevalence between the PHDC and other datasets are shown in Table 3 . A positive correlation was observed between PHDC and DHIS (r = 0.8). Table 3 Comparison of antenatal HIV prevalence between PHDC and other datasets (2014–2020) Datasets compared Mean absolute difference Mean difference Pearson’s correlation coefficient PHDC vs DHIS 0.8 0.4 r = 0.8 (p = 0.01) PHDC vs National Survey 1.4 -1.3 r = − 0.4 (p = 0.480) District level prevalence estimates are shown in Supplementary Fig. 1. Prevalence estimates between DHIS and PHDC were closely aligned from 2015 to 2020. PHDC and national antenatal survey district estimates were also closely aligned in 2017 and 2019 in all districts except Overberg, with an average percentage point difference of -4.4 from 2015 to 2020. HIV prevalence estimates remained stable over time among younger age-groups (aged 15–29 years) but increased among older age-groups (> 34 years). Prevalence estimates between PHDC and national antenatal survey data were closely aligned by age group (Fig. 2 ). Discussion This is the first study to compare sentinel HIV seroprevalence surveys with both routine aggregated and individuated data. Our results show that from 2015 onwards, the PHDC provides a reliable source of individuated data for accurate and timely antenatal HIV surveillance at provincial, district and age-group levels. These are essential for a responsive health system to plan and evaluate programmes. From 2015 onwards, the PHDC dataset enumerated more pregnancies than reflected in routine aggregate antenatal first visit registers (DHIS), supporting the completeness of these individuated data. The lower enumeration of pregnancies prior to 2015 is most likely due to limited availability of electronic data for linkage in earlier years, when electronic data systems were less widely established. As more public health facilities began using routine electronic data systems, patients with any contact with public health facilities would have some electronic record enabling inclusion in the PHDC. Given that the routine individuated data represent the entire population utilising public health services, these data are more representative of the population than survey data. It is also likely that linked individuated data are less prone to the biases of routine aggregated data such as duplication and lack of completeness, both numerically and within available records. A single unique identifier across the province prevents duplication of records where patients attend different facilities. Linkage of different electronic systems using a unique identifier also allows more opportunities for ascertainment of pregnancy and HIV status than fixed variables used in aggregate data. Comparison of descriptive characteristics between PHDC cohort and survey cohort enabled validation of the PHDC cohort prior to estimating HIV prevalence. The median age of women in the PHDC cohort (26.9 years) was similar to that in the antenatal survey population ( 3 , 6 ), supporting the close alignment in demographic profile of the two cohorts. PHDC, however, had a higher proportion of women with no prior evidence of pregnancy (60%) when compared to recorded gravidity in the survey (approximately 30%)( 3 , 6 ). This is likely due to less well-established electronic systems in earlier years for prior pregnancy ascertainment. Furthermore, the PHDC cohort had a higher proportion of patients from the Cape Metro district and lower proportion from the rural districts. This is also likely due to increased PHDC coverage in the Cape Metro, particularly in earlier years as electronic systems were better established in urban areas. The national surveys may further include oversampling of rural districts to generate accurate district-level estimates. We would suggest whole population surveillance negates a need for oversampling. HIV prevalence estimates in both national and provincial antenatal surveys remained consistent between 2011 and 2015, with provincial surveys providing more precise estimates due to the larger sample size. From 2014 onwards, PHDC estimates are closely aligned to the survey. Given the wide confidence intervals for survey estimates, trends are difficult to infer. DHIS HIV prevalence estimates for 2011 and 2012 were consistent with survey estimates, as shown in a comparative study ( 4 ). This study, however, used HIV-service specific denominators from DHIS viz. PMTCT initial HIV test acceptance or refusal. From 2014 onwards, refusal of PMTCT initial test was no longer recorded hence first antenatal visit was used as the denominator, resulting in lower estimates than in earlier years. DHIS data, however, showed an increasing proportion of women over time to be presenting for their first antenatal visit and known to be living with HIV. This increase corresponded with a decreasing proportion of women accepting HIV testing at first antenatal visit. The lower proportion of test acceptance is most likely due to increasing awareness of HIV positive status, in keeping with a recently published modelling study( 23 ). Additionally, some women with known HIV positive status may still retest in antenatal settings, as seen in a recent study in the Western Cape( 24 ). The change in DHIS elements likely represents the changing HIV context with greater awareness of HIV status and wider roll-out of antiretroviral therapy (ART) over time( 23 ). Variability presented in DHIS estimates is likely, in part, due to challenges in maintaining routine aggregate data systems where contextual factors, such as staff turnover, high workload, and social unrest impact data collection and consolidation from registers. PHDC HIV prevalence estimates 2011 to 2013 were lower than survey estimates, most likely due to incomplete electronic data. From 2014 onwards, estimates were better aligned and more consistent over time. As PHDC estimates do not distinguish between pregnancies with or without antenatal care, prevalence was expected to be slightly higher than that estimated using DHIS and survey data, as these data are limited to pregnancies with antenatal care. Antenatal first visit coverage is however high in the Western Cape at 94% and therefore the contribution of pregnancies without prior antenatal care to HIV prevalence is small in the PHDC estimates( 13 , 25 , 26 ). Reassuringly, PHDC estimates remained within the 95% confidence intervals of the national survey, and PHDC and DHIS estimates showed a positive correlation and low average difference. It should be noted, however, that average difference may mask the volatility of prevalence trends over time. Low average difference between survey and PHDC estimates suggest the PHDC may be reliably used to estimate antenatal HIV prevalence at provincial level. PHDC estimates over time were also similar to the Thembisa model estimates. Since the Thembisa model includes both private and public sector data, lower estimates than the PHDC were expected (reflecting lower HIV prevalence among private patients)( 27 ). At a more granular level, from 2015 onwards, estimates from PHDC were closely aligned to both DHIS and survey at district level, with disparities noted more in sparsely populated rural districts like Overberg. These disparities may reflect survey under-sampling in smaller rural districts as well as differences brought about by migrant populations such as workers( 28 ). Age-group HIV prevalence estimates from the PHDC were closely aligned to the national survey from 2015 onwards, showing consistent HIV prevalence in all age groups over a 5-year period, with higher estimates in older age groups. Higher prevalence in older age groups is expected due to a combination of factors, including increased cumulative incidence with age, and use of ART extending life expectancy. Since DHIS cannot provide age-disaggregated estimates, comparisons with PHDC and survey could not be made. Furthermore, in recent years, estimates at sub-district level are only possible with the PHDC data as the national survey is underpowered at sub-district level. This again highlights the advantages of linked individuated data over both survey data and aggregate routine data in providing granular estimates, not limited to predetermined indicators. Limitations A comparative study of this nature is subject to several limitations. Firstly, routine data were validated against sentinel surveillance data, with national surveys serving as the most accurate HIV prevalence estimates or “gold standard”. These survey estimates are however based on smaller sample sizes, over a limited time period, and underpowered for granular estimates which may impact accuracy. PHDC data were less reliable before 2014 due to incomplete electronic data in earlier years. Estimates from each dataset are derived using differing numerators and denominators with differing levels of quality and completeness. Furthermore, both individuated and aggregated routine data are subject to various pitfalls such as capturing errors, administrative errors and consolidation errors which may impact quality and completeness of these data. Pregnancy ascertainment may differ between districts and sub-districts due to differing use of electronic information systems. Since detailed patient characteristics such as socio-economic status and education level are not captured routinely, in-depth comparisons with survey data were not possible. Contextual factors impacting on observed trends in routine data are diverse and require further investigation – these include clerical changes in capturing approaches, widespread impact of the COVID-19 pandemic on service utilisation and staffing, migration patterns etc. Survey and routine data sources evaluated in this study include only patients utilising public health care services, excluding those in the private sector and those without access to public health care. Lastly, while the Western Cape province has established individuated data systems, most other provinces in South Africa are still reliant on aggregated register-based data. The results of this study are therefore not representative of the whole country and highlight the need and potential to strengthen individuated routine information systems for improved surveillance. Conclusion Our study demonstrates the validity of routine individuated data for timely and efficient HIV antenatal surveillance, without the additional cost and logistical complexity brought about by regular surveys and with fewer biases compared to routine aggregated data. We highlight the added utility of routine individuated data in providing more granular estimates than sentinel surveillance at district and sub-district level, thereby facilitating more detailed and timely population-level epidemiological trend analysis. While provincial antenatal HIV prevalence trends have increased slowly over time, notable differences in district level trends require further investigation. Strengthening of routine individuated data systems will create an actionable platform to support service delivery and allow richer, more efficient, less costly and more timeous HIV surveillance. Abbreviations ART Antiretroviral therapy DHIS District Health Information System PHDC Provincial Health Data Centre PMTCT Prevention–of–mother–to–child transmission Declarations Ethics approval and consent to participate The study was approved by the University of Cape Town Human Research Ethics Committee (HREC 083/2021) and the Western Cape Provincial Health Research Committee. All antenatal HIV survey data, DHIS and Thembisa data were provided in aggregated form. Verbal consent was obtained from survey participants as per survey protocol, however only aggregated survey data were provided for this study. Data from the PHDC were de-identified before release for the study according to the Western Cape Department of Health Data Access Policy Guidelines. Consent for publication Not applicable Availability of data and materials All antenatal HIV survey data, DHIS and Thembisa data were provided in aggregated form. The PHDC and DHIS data used in the study include unconsented, de-identified routine service data housed by the Western Cape Department of Health. Release of these data to a public domain would violate the Data Access Policy of the Western Cape Department of Health. Ethically approved data requests which may be targeting the same or similar data sources may be sent to or discussed with the Western Cape Provincial Department of Health and Wellness: [email protected] . The survey data are available from the National Department of Health, South Africa. Restrictions apply to the availability of these data, however these data may be requested from the National Department of Health, South Africa at [email protected] . Thembisa model data can be accessed from https://www.thembisa.org/. Competing interests The authors declare that they have no competing interests. Funding We gratefully acknowledge funding from the US National Institutes of Health (R01HD080465, U01AI069911), Bill and Melinda Gates Foundation (1164272; 1191327; INV-004657), the Wellcome Trust (203135/Z/16/Z), and the United States Agency for International Development (72067418CA00023). Authors’ contributions NJ, BR and AB conceptualised the study. NJ conducted the study, analysed the data and wrote the manuscript. AH, SB, TK and LJ contributed to data curation and provided data and analysis support. LJ, BR, AB, TK, AH, SB and AP made intellectual contributions to the manuscript. All authors read and approved the final manuscript. 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Comparison of adult HIV prevalence from national population-based surveys and antenatal clinic surveillance in countries with generalised epidemics: implications for calibrating surveillance data. Sex Transm Infect. 2008;84(Suppl I):i17–23. Fabiani M, Nattabi B, Ayella EO, Ogwang M, Declich S. Using prevalence data from the programme for the prevention of mother-to-child-transmission for HIV-1 surveillance in North Uganda. Aids. 2005;19(8):823–7. Kumar R, Virdi NK, Lakshmi PVM, Garg R, Bhattacharya M, Khera A. Utility of prevention of parent-to-child transmission (PPTCT) programme data for HIV surveillance in general population. Indian J Med Res. 2010;132(9):256–9. Hladik W, Masupu K, Roels T, Plipat T, Kaharuza F, Bunnell R et al. Prevention of mother-to-child transmission and voluntary counseling and testing programme data: What is their utility for HIV surveillance? AIDS, Suppl. 2005;19(2). Seguy N, Hladik W, Munyisia E, Bolu O, Marum LH, Diaz T. Can data from programs for the prevention of mother-to-child transmission of HIV be used for HIV surveillance in Kenya? Public Health Rep. 2006;121(6):695–702. Sirengo M, Rutherford GW, Otieno-nyunya B, Kellogg TA, Kimanga D, Muraguri N et al. Evaluation of Kenya ’ s readiness to transition from sentinel surveillance to routine HIV testing for antenatal clinic-based HIV surveillance. BMC Infect Dis [Internet]. 2016;1–6. http://dx.doi.org/10.1186/s12879-016-1434-1 . Johnson LF, Dorrington RE. Modelling the impact of HIV in South Africa’s provinces: 2023 update. Thembisa Version 4.6 [Internet]. 2023. [cited 2024 Jan 12] Available from: https://www.thembisa.org/downloads . Giguère K, Eaton JW, Marsh K, Johnson LF, Johnson CC, Ehui E, et al. Trends in knowledge of HIV status and efficiency of HIV testing services in sub-Saharan Africa, 2000–20 : a modelling study using survey and HIV testing programme data. Lancet HIV. 2021;8(May):284–93. Jacob N, Rice B, Kalk E, Heekes A, Morgan J, Hargreaves J et al. Utility of digitising point of care HIV test results to accurately measure, and improve performance towards, the UNAIDS 90-90-90 targets. PLoS One [Internet]. 2020;1–13. http://dx.doi.org/10.1371/journal.pone.0235471 . Massyn N, Day C, Ndlovu N, Padayachee T. District Health Barometer 2019/2020 [Internet]. Durban: Health Systems Trust; 2020. [cited 2022 Oct 23] Available from: https://www.hst.org.za/publications/Pages/HSTDistrictHealthBarometer.aspx . National Department of Health South Africa; Statistics South Africa (Stats SA); South African Medical Research Coucnil (SAMRC) and ICF. South Africa Demographic and Health Survey 2016 [Internet]. Pretroia, South Africa and Rockville Maryland, USA: NDoH, Stats SA, SAMRC and ICF. 2019. [cited 2020 Oct 23] Available from: https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf . Johnson LF, Dorrington RE, Moolla H. Progress towards the 2020 targets for HIV diagnosis and antiretroviral treatment in South Africa. South Afr J HIV Med. 2017;18(1):a694. Espinosa Dice AL, Bengtson AM, Mwenda KM, Colvin CJ, Lurie MN. Quantifying clinic transfers among people living with HIV in the Western Cape, South Africa: A retrospective spatial analysis. BMJ Open. 2021;11(12):1–9. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4065819","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":281198583,"identity":"31758a62-193b-4d0b-8794-690cc34f06ef","order_by":0,"name":"Nisha Jacob","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYDACZgY2IAnCPIwPSNbCbMDAYECUJjYozcMmQZQWc3b2Zw9+MPDJ87f3HqvmqfnDwN9+gPnDDzxaLJt5zA17GNgMZ5w5l3ab55gBg8SZBAagCG5gcBjoHh4GNsYNEjlmt3kbgA67wcCQwINXC/szyT8MbPYgLcUgLfJALQf/4NXCYCYNtCURpIUZpMXgBgNjM35beMykZQzYkoF+SZacc8yYx/BMYjOzDD4t548/k3xTccy2v7334Ic3NXJycscPH/74Bo8WqMZjcCbQSYwNBDUAQQ0xikbBKBgFo2CkAgDIvkDTC6MpdgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Cape Town","correspondingAuthor":true,"prefix":"","firstName":"Nisha","middleName":"","lastName":"Jacob","suffix":""},{"id":281198584,"identity":"0d661632-55ea-41b4-bb5d-b25e0d0df142","order_by":1,"name":"Brian Rice","email":"","orcid":"","institution":"University of Sheffield","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Rice","suffix":""},{"id":281198589,"identity":"8d09e7ba-0f0a-4a5f-ac3d-881019886617","order_by":2,"name":"Alexa Heekes","email":"","orcid":"","institution":"University of Cape Town","correspondingAuthor":false,"prefix":"","firstName":"Alexa","middleName":"","lastName":"Heekes","suffix":""},{"id":281198592,"identity":"cd18c3bc-7394-4300-8651-aa5804f7e9d6","order_by":3,"name":"Leigh F. Johnson","email":"","orcid":"","institution":"University of Cape Town","correspondingAuthor":false,"prefix":"","firstName":"Leigh","middleName":"F.","lastName":"Johnson","suffix":""},{"id":281198593,"identity":"331726c7-4c66-4587-a048-84f799677303","order_by":4,"name":"Samantha Brinkmann","email":"","orcid":"","institution":"Western Cape Government: Health and Wellness","correspondingAuthor":false,"prefix":"","firstName":"Samantha","middleName":"","lastName":"Brinkmann","suffix":""},{"id":281198595,"identity":"a5b38b37-b632-4fa6-9a57-81787e893e85","order_by":5,"name":"Tendesayi Kufa","email":"","orcid":"","institution":"National Institute for Communicable Diseases","correspondingAuthor":false,"prefix":"","firstName":"Tendesayi","middleName":"","lastName":"Kufa","suffix":""},{"id":281198597,"identity":"3db03602-fbde-420d-ac08-2d2eef07e613","order_by":6,"name":"Adrian Puren","email":"","orcid":"","institution":"National Institute for Communicable Diseases","correspondingAuthor":false,"prefix":"","firstName":"Adrian","middleName":"","lastName":"Puren","suffix":""},{"id":281198599,"identity":"20b6b8da-33bd-4f72-9716-542cdce15982","order_by":7,"name":"Andrew Boulle","email":"","orcid":"","institution":"University of Cape Town","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Boulle","suffix":""}],"badges":[],"createdAt":"2024-03-10 14:45:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4065819/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4065819/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-10639-6","type":"published","date":"2025-03-04T15:57:59+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":53187266,"identity":"63ae301c-b4b5-4146-a887-97f2267488c6","added_by":"auto","created_at":"2024-03-21 16:35:35","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":174164,"visible":true,"origin":"","legend":"\u003cp\u003eWestern Cape Antenatal HIV Prevalence 2011 – 2020 by dataset\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4065819/v1/3dae2b182d68d3a3f5036dda.jpg"},{"id":53187268,"identity":"63c6e12b-e396-4f44-8d77-91327d0d1f4a","added_by":"auto","created_at":"2024-03-21 16:35:35","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":300944,"visible":true,"origin":"","legend":"\u003cp\u003eWestern Cape Antenatal HIV Prevalence by Age Group: 2015 – 2020 (PHDC and National Antenatal Survey)\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4065819/v1/41d51253004748629c387aae.jpg"},{"id":78190353,"identity":"b4101492-fc3b-4fbf-9db1-f55e88b14a21","added_by":"auto","created_at":"2025-03-10 19:48:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1543156,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4065819/v1/a598b4c0-0520-412f-a03e-6511858e9235.pdf"},{"id":53187267,"identity":"23f5fdfd-2222-4d68-9f5a-a43baad5a48c","added_by":"auto","created_at":"2024-03-21 16:35:35","extension":"tif","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":332230,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1S.tif","url":"https://assets-eu.researchsquare.com/files/rs-4065819/v1/17e9a1531af491d42fe0a833.tif"},{"id":53187271,"identity":"26a4283f-657f-4124-aa2e-6dccce1455f7","added_by":"auto","created_at":"2024-03-21 16:35:36","extension":"tif","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":346574,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2S.tif","url":"https://assets-eu.researchsquare.com/files/rs-4065819/v1/a0f135c5273fbb66fa3210f8.tif"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the validity of routine individuated service data for antenatal HIV surveillance in the Western Cape","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMonitoring the progress of HIV programmes is reliant, in part, on robust surveillance. Whilst global HIV surveillance has evolved since the beginning of the epidemic(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), survey-based approaches remain the mainstay in many settings. Since 1990, the National Antenatal Sentinel HIV Survey has been conducted among pregnant women at selected public health antenatal clinics in all nine provinces of South Africa annually or biennially(\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Until 2015, the surveys were limited to women presenting for their first antenatal visit, but since then follow-up antenatal visits have also been included(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Due to the national antenatal survey being underpowered to provide accurate estimates at district and sub-district level, the Western Cape Provincial Department of Health expanded the national survey to additional sites from 2001 to 2015 to generate more accurate sub-provincial estimates(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 2013, WHO and UNAIDS published \u003cem\u003eGuiding principles on ethical issues in HIV surveillance\u003c/em\u003e indicating that unlinked anonymous testing should only be used where there is demonstrable inadequacy of program data for surveillance purposes(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The WHO 2015 C\u003cem\u003eonsolidated guidelines on HIV testing services\u003c/em\u003e, and the WHO 2022 \u003cem\u003eConsolidated guidelines on person-centred HIV strategic information\u003c/em\u003e, recommend moving towards using routine programmatic data for antenatal HIV surveillance(\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). To facilitate this transition in surveillance strategy, evaluations of routine data are required. A 2020 assessment of the national prevention-of-mother-to child programme concluded that South Africa was close to achieving the transition to routine data surveillance in relation to HIV testing, but that further evaluation of data completeness and accuracy was required(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). While these studies look specifically at the validity of routine HIV testing data in comparison to laboratory-based HIV testing data from surveys, it should be emphasised that HIV patient management in South Africa is based on routine HIV point-of-care testing results. Reassuringly, available literature shows high antenatal HIV testing coverage in South Africa of up to 98% by 2011(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Use of routine data for surveillance purposes requires further validation with other surveillance data sources.\u003c/p\u003e \u003cp\u003eIn the Western Cape province of South Africa there are two routine programmatic health information systems related to maternal and HIV care. Aggregated provincial data captured from service-based registers are housed in the District Health Information System (DHIS)(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The HIV testing services register comprises 46 reporting elements (manual and calculated) for key HIV indicators. The Western Cape Provincial Government has additionally developed a Provincial Health Data Centre (PHDC) in which all individual-level routine data captured electronically in the province are consolidated on a single platform, leveraging the patient folder number as the unique patient identifier(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This allows linkage of various information systems, including laboratory, pharmacy, and patient administration data, providing a rich source of individuated health information, in the absence of routine electronic patient health records. Within this environment, disease-specific patient cascades (virtual cohorts), such as the HIV care cascade and maternity cascade, may be developed using specific markers of care at different points(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral studies in low- and middle-income countries have compared antenatal survey estimates with routine HIV data(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). A 2013 study in the Western Cape showed comparable estimates between antenatal survey data and aggregated antenatal HIV data, but also reported disparities at the sub-district level(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). To date there have been no studies in the South African context comparing antenatal survey HIV estimates with \u003cem\u003eindividuated\u003c/em\u003e routine data estimates. We sought to evaluate the validity of routine HIV prevalence estimates in pregnant women in the Western Cape Province of South Africa as compared to sentinel surveillance.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eThe study was set in the Western Cape province of South Africa, which is comprised of one metropolitan district, Cape Metro and five less urbanised districts (Overberg, Garden Route, Central Karoo, West Coast and Cape Winelands). We compared cross-sectional HIV antenatal survey estimates to those derived from aggregated program data and individuated program data 2011 to 2020. To evaluate the validity of routine HIV prevalence estimates in pregnant women we analysed four datasets; these are described below.\u003c/p\u003e\n\u003ch3\u003eNational antenatal survey data\u003c/h3\u003e\n\u003cp\u003eNational sentinel antenatal survey HIV prevalence estimates for the Western Cape province were obtained from the South African National Department of Health. District-level and age-disaggregated estimates were provided on all pregnant women attending their first antenatal visit in a public health facility in the Western Cape during a 6-week survey period in the years 2011\u0026ndash;2015. Post 2015, the national antenatal survey was conducted biennially. In years 2015, 2017 and 2019, the national survey data included pregnant women attending first antenatal visits or follow-up antenatal visits in a public health facility during a 6-week period. However, to promote consistency with earlier surveys, we limit our estimates to first antenatal visit. Blood specimens of survey participants were tested for HIV at a central laboratory using HIV ELISA tests.\u003c/p\u003e\n\u003ch3\u003eExpanded provincial antenatal survey data\u003c/h3\u003e\n\u003cp\u003eProvincial sentinel antenatal survey data 2011\u0026ndash;2015 (subsequently discontinued), incorporating larger, proportionally weighted sample sizes, were obtained from the Western Cape Department of Health. To attain provincial estimates, sub-district data were weighted using the proportional distribution of antenatal first visits in the prior year.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDHIS (Routine aggregated HIV program data)\u003c/h2\u003e \u003cp\u003eAggregated program data included all women attending their first antenatal visit at primary health care facilities in the Western Cape 2011\u0026ndash;2020. All women, regardless of HIV status, are offered a point-of-care HIV test at first antenatal visit. Results of these tests are captured in facility-based registers, initially prevention-of-mother-to-child transmission (PMTCT) register and later primary health care services register. As PMTCT register data were limited from 2011\u0026ndash;2013, provincial estimates from 2011 and 2012 were obtained from a study comparing routine aggregated data to sentinel surveys(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). From 2014 to 2020, the proportion of pregnant women at first visit with evidence of prior HIV diagnosis or new diagnosis, derived from the primary health care services register, was used to calculate prevalence estimates. \u0026ldquo;HIV positive PMTCT initial test\u0026rdquo; and \u0026ldquo;Known HIV positive client\u0026rdquo; elements were combined as the numerator, with total \u0026ldquo;Antenatal first visit\u0026rdquo; as the denominator. Routine HIV testing is based on a point-of-care HIV testing algorithm conducted by an HIV counsellor or nurse, where only discordant test results are confirmed by central laboratory-based ELISA testing. Known HIV positive status is captured by an HIV counsellor or nurse based on self-reported HIV and medical records confirming HIV diagnosis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePHDC (Routine individuated HIV program data)\u003c/h2\u003e \u003cp\u003eA retrospective cohort was derived from the PHDC which included de-identified linked data of all pregnant women attending public health facilities across the province 2011\u0026ndash;2020. The cohort was enumerated using the PHDC maternity cascade which links electronic records of all patients with administrative or laboratory evidence indicative of pregnancy. Pregnancies inferred with high confidence were included, as they have at least one high confidence evidence such as a rhesus antibody test (conducted routinely at first antenatal visit), pregnancy test, International Classification of Diseases (ICD) Tenth Revision code indicating pregnancy or pregnancy outcome, maternal discharge summary or repeat moderate confidence evidences such as antenatal visits. Since information specific to the first visit is not routinely captured in all public health facilities, it was not possible to distinguish between first and follow-up antenatal visits, however all pregnancies were only captured once. District and sub-district for pregnancy was determined by the geographic location of the facility of first pregnancy evidence. The pregnancy period was estimated using the pregnancy outcome date and/or any available evidence on gestational age, with year allocated according to the date of first record of pregnancy. Since HIV diagnosis is based on point-of-care testing, these results are not digitised and therefore not available to the PHDC. In the absence of these testing data, administrative, laboratory and pharmacy evidence of HIV diagnosis before or during the estimated pregnancy period was used to determine antenatal HIV status of women in the maternity cohort. The proportion of pregnancies with electronic evidence of HIV diagnosis prior to pregnancy or during pregnancy amongst all pregnant women was used to calculate antenatal HIV prevalence estimates.\u003c/p\u003e \u003cp\u003eAnalysis\u003c/p\u003e \u003cp\u003eData were analysed using Microsoft Excel and Stata 17 (Stata Corporation, College Station, Texas, USA). Measures of central tendency and dispersion were used to describe continuous variables, depending on distribution. Categorical variables were described using proportions and 95% confidence intervals, using the normal approximation to the binomial distribution. Descriptive characteristics of the PHDC cohort (2014\u0026ndash;2020) were validated with 2014 provincial antenatal survey data. Prevalence estimates from provincial surveys, and aggregated and individuated program data, were calculated for comparison with national survey estimates, serving as the gold standard in this comparative analysis. Data were analysed by year at provincial and district level for comparison.\u003c/p\u003e \u003cp\u003eProvincial estimates from all datasets were further compared with provincial antenatal HIV prevalence estimates from the Thembisa mathematical model(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). This is an integrated demographic and HIV model for South Africa, calibrated to a number of HIV data sources including antenatal HIV prevalence surveys(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Quantitative comparisons were analysed using correlation coefficients and average percentage differences. Individuated data from 2015 onwards were further disaggregated by district and age for prevalence estimates. Provincial age-group estimates were compared between PHDC and the national antenatal survey from 2015. There were no comparators available for district-level age group estimates as the national antenatal survey is underpowered for this purpose. Data were categorised using age categories routinely used in antenatal survey reporting.\u003c/p\u003e \u003cp\u003eThe DHIS estimates (2011\u0026ndash;2020) and survey estimates (2011\u0026ndash;2015) are limited to pregnancies registered for antenatal care, whereas PHDC estimates (2011\u0026ndash;2020) include all pregnancies.\u003c/p\u003e \u003cp\u003eEthical considerations\u003c/p\u003e \u003cp\u003eThe study was approved by the University of Cape Town Human Research Ethics Committee (HREC 083/2021) and the Western Cape Provincial Health Research Committee. All antenatal HIV sentinel survey and DHIS data were received as aggregates. Data from the PHDC were de-identified before release for the study according to the Western Cape Department of Health Data Access Policy Guidelines.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFrom 1 January 2011 to 31 December 2020, 977 800 and 989 568 pregnancies were enumerated by the PHDC and DHIS, respectively. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents study population size per year compared with sample sizes of both provincial and national antenatal surveys. As compared to the DHIS, fewer pregnancies were enumerated by PHDC prior to 2015.\u003c/p\u003e\n\u003cp\u003eAmongst women presenting for their first antenatal visit as recorded in the DHIS aggregated data, the percentage known to be living with HIV increased from 9.5% (95% CI 9.4\u0026ndash;9.7%) in 2014 to 15.0% (95% CI 14.8\u0026ndash;15.2%) in 2020. Over the same period, the percentage of women accepting an HIV test at first antenatal visit declined from 90.4% (95% CI 90.2\u0026ndash;90.6%) to 81.0% (95% CI 80.8\u0026ndash;81.2) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The characteristics of the women participating in the PHDC cohort (2014\u0026ndash;2020) and the 2014 antenatal survey (unweighted) are shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. As seen in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, PHDC HIV prevalence estimates from 2014 onwards are closely aligned to national, provincial and DHIS data.\u003c/p\u003e\n\u003ch3\u003eTable 1: Antenatal HIV prevalence estimates by dataset\u003c/h3\u003e\n\u003ctable\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" style=\"width:45.1pt;border:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;height:22.5pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" rowspan=\"2\" style=\"width:255.75pt;border:solid windowtext 1.0pt;border-left:none;padding:0cm 5.4pt 0cm 5.4pt;height:22.5pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003ePregnancies (N)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width:101.7pt;border:solid windowtext 1.0pt;border-left:none;padding:0cm 5.4pt 0cm 5.4pt;height:22.5pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003eHIV testing (DHIS)\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" rowspan=\"2\" style=\"width:283.35pt;border:solid windowtext 1.0pt;border-left:none;padding:0cm 5.4pt 0cm 5.4pt;height:22.5pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003eHIV prevalence\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size:12px;color:black;\"\u003e\u0026sect;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0cm 0cm 0cm 0cm;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:8.0pt;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height:22.5pt;border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.1pt;padding: 0cm 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"height:15.0pt;border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width:47.65pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003eNational Survey\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:53.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003eProvincial Survey\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:46.7pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003eDHIS\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:46.7pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#FFE599;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003ePHDC\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:60.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9D9D9;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003eDHIS/PHDC difference\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:50.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003eKnown HIV positive among all first antenatal visits (%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:51.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003eAccepted testing among all first antenatal visits (%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"4\" style=\"width:105.75pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003eNational Survey \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (%, 95% CI)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"4\" style=\"width:93.65pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003eProvincial Survey \u0026nbsp; \u0026nbsp; \u0026nbsp;(%, 95% CI)\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:38.0pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E2F3;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003eDHIS (%)\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:45.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#FFE599;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family: \"Arial\",sans-serif;color:black;'\u003ePHDC (%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:11.1pt;padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"height:15.0pt;border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.1pt;padding: 0cm 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"height:15.0pt;border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.1pt;padding: 0cm 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"height:15.0pt;border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.1pt;padding: 0cm 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"height:15.0pt;border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:45.1pt;border:solid windowtext 1.0pt;border-top: none;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e2011\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:47.65pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e4044\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e9812\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e97588\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e46703\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:60.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9D9D9;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e-50885\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:50.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:51.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.4pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e18.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:69.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e14.3 - 22.8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e18.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:2.0cm;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e17.7 - 19.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:38.0pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E2F3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e18.4\u0026Dagger;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e11.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:11.1pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"height:24.0pt;border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:45.1pt;border:solid windowtext 1.0pt;border-top: none;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e2012\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:47.65pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e4010\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e8711\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e97144\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e59826\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:60.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9D9D9;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e-37318\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:50.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:51.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.4pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e16.9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:69.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e13.8 - 20.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e17.8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:2.0cm;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e16.7 - 18.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:38.0pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E2F3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e18.7\u0026Dagger;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e12.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:11.1pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"height:24.0pt;border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:45.1pt;border:solid windowtext 1.0pt;border-top: none;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e2013\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:47.65pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e3793\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e8125\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e96993\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e81761\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:60.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9D9D9;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e-15232\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:50.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:51.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.4pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e18.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:69.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e15.1 - 23.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e17.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:2.0cm;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e16.4 - 18.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:38.0pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E2F3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e14.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:11.1pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"height:24.0pt;border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:45.1pt;border:solid windowtext 1.0pt;border-top: none;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e2014\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:47.65pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e4036\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e7480\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e99454\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e94200\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:60.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9D9D9;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e-5254\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:50.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e9.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:51.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e89.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.4pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e18.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:69.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e15.7 - 22.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e18.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:2.0cm;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e17.7 - 19.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:38.0pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E2F3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e15.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e15.9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:11.1pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"height:24.0pt;border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:45.1pt;border:solid windowtext 1.0pt;border-top: none;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e2015\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:47.65pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e7517\u0026dagger;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e7560\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e92168\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e101730\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:60.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9D9D9;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e9562\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:50.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e9.8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:51.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e90.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.4pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e18.9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:69.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e16.4 - 21.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e17.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:2.0cm;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e16.8 - 18.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:38.0pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E2F3;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e15.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:24.0pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan 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5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e109664\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:46.7pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e127166\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:60.85pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9D9D9;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e17502\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:50.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e15.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:51.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#D9E1F2;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e81.0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.4pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:69.35pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#A8D08D;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:36.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:2.0cm;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #C5E0B3;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:38.0pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #D9E2F3;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e17.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.95pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#FFE699;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-size:12px;font-family:\"Arial\",sans-serif;color:black;'\u003e18.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:11.1pt;padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"height:15.75pt;border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026dagger;2015 national survey included additional Western Cape data and was limited to women presenting for first antenatal visit.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026Dagger;2011 and 2012 DHIS estimates denominator was total number of women refusing or accepting PMTCT initial tests whereas later estimates used the denominator of total antenatal visits\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e*Prevalence estimate is among first antenatal visit only. 2017 reported prevalence including both first and follow-up attendees is 15.9% (95% CI 14.2 -17.8).\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e**Prevalence estimate is among first antenatal visits only. 2019 reported prevalence including both first and follow-up attendees is 17.9% (95% CI 16.2 \u0026ndash; 19.7).\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026sect;95% Confidence intervals are not reported for routine data estimates as the whole population is included precluding the need for sampling\u003c/em\u003e\u003c/p\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDescriptive characteristics of PHDC Cohort (2014\u0026ndash;2020) compared to 2014 Provincial Antenatal Survey\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePHDC Cohort 2014\u0026ndash;2020 (n\u0026thinsp;=\u0026thinsp;789510) Percentage\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAntenatal survey 2014 (n\u0026thinsp;=\u0026thinsp;7526)\u003c/p\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eElectronic evidence of current and prior pregnancy*\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57.8\u0026ndash;58.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.4\u0026ndash;31.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.9\u0026ndash;28.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.9\u0026ndash;33.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.2\u0026ndash;10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.8\u0026ndash;22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.9\u0026ndash;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.5\u0026ndash;10.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e5 or more\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.9\u0026ndash;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.3\u0026ndash;6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (median; IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.0 (22.6\u0026ndash;32.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.4 (22.0\u0026ndash;31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.4\u0026ndash;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3\u0026ndash;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u0026ndash;19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.7\u0026ndash;11.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.7\u0026ndash;14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e20\u0026ndash;24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.3\u0026ndash;26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.5\u0026ndash;29.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e25\u0026ndash;29\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.2\u0026ndash;27.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.9\u0026ndash;27.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e30\u0026ndash;34\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.4\u0026ndash;20.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.9\u0026ndash;20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e35\u0026ndash;39\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.5\u0026ndash;10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.0\u0026ndash;9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;\u0026thinsp;39\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.0\u0026ndash;3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.8\u0026ndash;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistrict**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCape Winelands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.7\u0026ndash;13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.0\u0026ndash;16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCentral Karoo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.95\u0026ndash;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.3\u0026ndash;1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCape Metro\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.3\u0026ndash;67.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51.8\u0026ndash;54.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGarden Route\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.9\u0026ndash;9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.2\u0026ndash;15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOverberg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.5\u0026ndash;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.0\u0026ndash;6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWest Coast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.5\u0026ndash;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.5\u0026ndash;9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo district recorded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.7\u0026ndash;0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003cem\u003e*Gravidity estimates (number of times a woman has been pregnant, including current pregnancy) in the PHDC are not reliable since historic data are incomplete. Electronic evidence of current and prior pregnancy is used as a proxy to provide a full description of the cohort.\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003cem\u003e**Unweighted\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe average difference in antenatal HIV prevalence between the PHDC and other datasets are shown in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. A positive correlation was observed between PHDC and DHIS (r\u0026thinsp;=\u0026thinsp;0.8).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of antenatal HIV prevalence between PHDC and other datasets (2014\u0026ndash;2020)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDatasets compared\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean absolute difference\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean difference\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePearson\u0026rsquo;s correlation coefficient\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHDC vs DHIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u0026thinsp;=\u0026thinsp;0.8 (p\u0026thinsp;=\u0026thinsp;0.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHDC vs National Survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.4 (p\u0026thinsp;=\u0026thinsp;0.480)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eDistrict level prevalence estimates are shown in Supplementary Fig.\u0026nbsp;1. Prevalence estimates between DHIS and PHDC were closely aligned from 2015 to 2020. PHDC and national antenatal survey district estimates were also closely aligned in 2017 and 2019 in all districts except Overberg, with an average percentage point difference of -4.4 from 2015 to 2020.\u003c/p\u003e\n\u003cp\u003eHIV prevalence estimates remained stable over time among younger age-groups (aged 15\u0026ndash;29 years) but increased among older age-groups (\u0026gt;\u0026thinsp;34 years). Prevalence estimates between PHDC and national antenatal survey data were closely aligned by age group (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first study to compare sentinel HIV seroprevalence surveys with both routine aggregated and individuated data. Our results show that from 2015 onwards, the PHDC provides a reliable source of individuated data for accurate and timely antenatal HIV surveillance at provincial, district and age-group levels. These are essential for a responsive health system to plan and evaluate programmes.\u003c/p\u003e \u003cp\u003eFrom 2015 onwards, the PHDC dataset enumerated more pregnancies than reflected in routine aggregate antenatal first visit registers (DHIS), supporting the completeness of these individuated data. The lower enumeration of pregnancies prior to 2015 is most likely due to limited availability of electronic data for linkage in earlier years, when electronic data systems were less widely established. As more public health facilities began using routine electronic data systems, patients with any contact with public health facilities would have some electronic record enabling inclusion in the PHDC. Given that the routine individuated data represent the entire population utilising public health services, these data are more representative of the population than survey data. It is also likely that linked individuated data are less prone to the biases of routine aggregated data such as duplication and lack of completeness, both numerically and within available records. A single unique identifier across the province prevents duplication of records where patients attend different facilities. Linkage of different electronic systems using a unique identifier also allows more opportunities for ascertainment of pregnancy and HIV status than fixed variables used in aggregate data.\u003c/p\u003e \u003cp\u003eComparison of descriptive characteristics between PHDC cohort and survey cohort enabled validation of the PHDC cohort prior to estimating HIV prevalence. The median age of women in the PHDC cohort (26.9 years) was similar to that in the antenatal survey population (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), supporting the close alignment in demographic profile of the two cohorts. PHDC, however, had a higher proportion of women with no prior evidence of pregnancy (60%) when compared to recorded gravidity in the survey (approximately 30%)(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This is likely due to less well-established electronic systems in earlier years for prior pregnancy ascertainment. Furthermore, the PHDC cohort had a higher proportion of patients from the Cape Metro district and lower proportion from the rural districts. This is also likely due to increased PHDC coverage in the Cape Metro, particularly in earlier years as electronic systems were better established in urban areas. The national surveys may further include oversampling of rural districts to generate accurate district-level estimates. We would suggest whole population surveillance negates a need for oversampling.\u003c/p\u003e \u003cp\u003eHIV prevalence estimates in both national and provincial antenatal surveys remained consistent between 2011 and 2015, with provincial surveys providing more precise estimates due to the larger sample size. From 2014 onwards, PHDC estimates are closely aligned to the survey. Given the wide confidence intervals for survey estimates, trends are difficult to infer. DHIS HIV prevalence estimates for 2011 and 2012 were consistent with survey estimates, as shown in a comparative study (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This study, however, used HIV-service specific denominators from DHIS viz. PMTCT initial HIV test acceptance or refusal. From 2014 onwards, refusal of PMTCT initial test was no longer recorded hence first antenatal visit was used as the denominator, resulting in lower estimates than in earlier years. DHIS data, however, showed an increasing proportion of women over time to be presenting for their first antenatal visit and known to be living with HIV. This increase corresponded with a decreasing proportion of women accepting HIV testing at first antenatal visit. The lower proportion of test acceptance is most likely due to increasing awareness of HIV positive status, in keeping with a recently published modelling study(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Additionally, some women with known HIV positive status may still retest in antenatal settings, as seen in a recent study in the Western Cape(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The change in DHIS elements likely represents the changing HIV context with greater awareness of HIV status and wider roll-out of antiretroviral therapy (ART) over time(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Variability presented in DHIS estimates is likely, in part, due to challenges in maintaining routine aggregate data systems where contextual factors, such as staff turnover, high workload, and social unrest impact data collection and consolidation from registers.\u003c/p\u003e \u003cp\u003ePHDC HIV prevalence estimates 2011 to 2013 were lower than survey estimates, most likely due to incomplete electronic data. From 2014 onwards, estimates were better aligned and more consistent over time. As PHDC estimates do not distinguish between pregnancies with or without antenatal care, prevalence was expected to be slightly higher than that estimated using DHIS and survey data, as these data are limited to pregnancies with antenatal care. Antenatal first visit coverage is however high in the Western Cape at 94% and therefore the contribution of pregnancies without prior antenatal care to HIV prevalence is small in the PHDC estimates(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Reassuringly, PHDC estimates remained within the 95% confidence intervals of the national survey, and PHDC and DHIS estimates showed a positive correlation and low average difference. It should be noted, however, that average difference may mask the volatility of prevalence trends over time. Low average difference between survey and PHDC estimates suggest the PHDC may be reliably used to estimate antenatal HIV prevalence at provincial level. PHDC estimates over time were also similar to the Thembisa model estimates. Since the Thembisa model includes both private and public sector data, lower estimates than the PHDC were expected (reflecting lower HIV prevalence among private patients)(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAt a more granular level, from 2015 onwards, estimates from PHDC were closely aligned to both DHIS and survey at district level, with disparities noted more in sparsely populated rural districts like Overberg. These disparities may reflect survey under-sampling in smaller rural districts as well as differences brought about by migrant populations such as workers(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Age-group HIV prevalence estimates from the PHDC were closely aligned to the national survey from 2015 onwards, showing consistent HIV prevalence in all age groups over a 5-year period, with higher estimates in older age groups. Higher prevalence in older age groups is expected due to a combination of factors, including increased cumulative incidence with age, and use of ART extending life expectancy. Since DHIS cannot provide age-disaggregated estimates, comparisons with PHDC and survey could not be made. Furthermore, in recent years, estimates at sub-district level are only possible with the PHDC data as the national survey is underpowered at sub-district level. This again highlights the advantages of linked individuated data over both survey data and aggregate routine data in providing granular estimates, not limited to predetermined indicators.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eA comparative study of this nature is subject to several limitations. Firstly, routine data were validated against sentinel surveillance data, with national surveys serving as the most accurate HIV prevalence estimates or \u0026ldquo;gold standard\u0026rdquo;. These survey estimates are however based on smaller sample sizes, over a limited time period, and underpowered for granular estimates which may impact accuracy. PHDC data were less reliable before 2014 due to incomplete electronic data in earlier years. Estimates from each dataset are derived using differing numerators and denominators with differing levels of quality and completeness. Furthermore, both individuated and aggregated routine data are subject to various pitfalls such as capturing errors, administrative errors and consolidation errors which may impact quality and completeness of these data. Pregnancy ascertainment may differ between districts and sub-districts due to differing use of electronic information systems. Since detailed patient characteristics such as socio-economic status and education level are not captured routinely, in-depth comparisons with survey data were not possible. Contextual factors impacting on observed trends in routine data are diverse and require further investigation \u0026ndash; these include clerical changes in capturing approaches, widespread impact of the COVID-19 pandemic on service utilisation and staffing, migration patterns etc. Survey and routine data sources evaluated in this study include only patients utilising public health care services, excluding those in the private sector and those without access to public health care. Lastly, while the Western Cape province has established individuated data systems, most other provinces in South Africa are still reliant on aggregated register-based data. The results of this study are therefore not representative of the whole country and highlight the need and potential to strengthen \u003cem\u003eindividuated\u003c/em\u003e routine information systems for improved surveillance.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study demonstrates the validity of routine individuated data for timely and efficient HIV antenatal surveillance, without the additional cost and logistical complexity brought about by regular surveys and with fewer biases compared to routine aggregated data. We highlight the added utility of routine individuated data in providing more granular estimates than sentinel surveillance at district and sub-district level, thereby facilitating more detailed and timely population-level epidemiological trend analysis. While provincial antenatal HIV prevalence trends have increased slowly over time, notable differences in district level trends require further investigation. Strengthening of routine individuated data systems will create an actionable platform to support service delivery and allow richer, more efficient, less costly and more timeous HIV surveillance.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eART\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntiretroviral therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDHIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDistrict Health Information System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHDC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProvincial Health Data Centre\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePMTCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrevention\u0026ndash;of\u0026ndash;mother\u0026ndash;to\u0026ndash;child transmission\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe study was approved by the University of Cape Town Human Research Ethics Committee (HREC 083/2021) and the Western Cape Provincial Health Research Committee. All antenatal HIV survey data, DHIS and Thembisa data were provided in aggregated form. Verbal consent was obtained from survey participants as per survey protocol, however only aggregated survey data were provided for this study.\u003c/p\u003e\n\u003cp\u003eData from the PHDC were de-identified before release for the study according to the Western Cape Department of Health Data Access Policy Guidelines.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eAll antenatal HIV survey data, DHIS and Thembisa data were provided in aggregated form. The PHDC and DHIS data used in the study include unconsented, de-identified routine service data housed by the Western Cape Department of Health. Release of these data to a public domain would violate the Data Access Policy of the Western Cape Department of Health. Ethically approved data requests which may be targeting the same or similar data sources may be sent to or discussed with the Western Cape Provincial Department of Health and Wellness: [email protected]. The survey data are available from the National Department of Health, South Africa. Restrictions apply to the availability of these data, however these data may be requested from the National Department of Health, South Africa at [email protected]. Thembisa model data can be accessed from https://www.thembisa.org/.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding \u003c/h2\u003e\n\u003cp\u003eWe gratefully acknowledge funding from the US National Institutes of Health (R01HD080465, U01AI069911), Bill and Melinda Gates Foundation (1164272; 1191327; INV-004657), the Wellcome Trust (203135/Z/16/Z), and the United States Agency for International Development (72067418CA00023).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eNJ, BR and AB conceptualised the study. NJ conducted the study, analysed the data and wrote the manuscript. AH, SB, TK and LJ contributed to data curation and provided data and analysis support. LJ, BR, AB, TK, AH, SB and AP made intellectual contributions to the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors gratefully acknowledge the contributions of various collaborators, including Selamawit Woldesenbet, Emma Kalk, Florence Phelenyane, Vanessa Mudaly, the Western Cape Department of Health, the National Institute of Communicable Diseases and the Measurement and Surveillance of HIV Epidemics (MeSH) consortium.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePisani E, Lazzari S, Walker N, Schwartlander B. HIV Surveillance: A Global Perspective. J Acquir Immune Defic Syndr. 2003;32:S3\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNAIDS/WHO. Guidelines for Second Generation HIV Surveillance [Internet]. 2000 [cited 2020 Oct 23]. 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Public Health Rep. 2006;121(6):695\u0026ndash;702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSirengo M, Rutherford GW, Otieno-nyunya B, Kellogg TA, Kimanga D, Muraguri N et al. Evaluation of Kenya \u0026rsquo; s readiness to transition from sentinel surveillance to routine HIV testing for antenatal clinic-based HIV surveillance. BMC Infect Dis [Internet]. 2016;1\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1186/s12879-016-1434-1\u003c/span\u003e\u003cspan address=\"10.1186/s12879-016-1434-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson LF, Dorrington RE. Modelling the impact of HIV in South Africa\u0026rsquo;s provinces: 2023 update. Thembisa Version 4.6 [Internet]. 2023. 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BMJ Open. 2021;11(12):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HIV surveillance, sentinel surveys, routine data, HIV prevalence","lastPublishedDoi":"10.21203/rs.3.rs-4065819/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4065819/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn the Western Cape, South Africa, public-sector individual-level routine data are consolidated from multiple sources through the Provincial Health Data Centre (PHDC). This enables the description of temporal changes in population-wide antenatal HIV seroprevalence. We evaluated the validity of these data compared to aggregated program data and population-wide sentinel antenatal HIV seroprevalence surveys for the Western Cape province.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective cohort analysis of all pregnancies identified in the PHDC from January 2011 to December 2020. Evidence of antenatal and HIV care from electronic platforms were linked using a unique patient identifier. HIV prevalence estimates were triangulated and compared with available survey estimates and aggregated programmatic data from registers as recorded in the District Health Information System. Provincial, district-level and age-group HIV prevalence estimates were compared between data systems using correlation coefficients, absolute differences and trend analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 977800 pregnancies ascertained, PHDC HIV prevalence estimates from 2011\u0026ndash;2013 were widely disparate from aggregate and survey data (due to incomplete electronic data), whereas from 2014 onwards, estimates were within the 95% confidence interval of survey estimates, and closely correlated to aggregate data estimates (r\u0026thinsp;=\u0026thinsp;0.8; p\u0026thinsp;=\u0026thinsp;0.01), with an average prevalence difference of 0.4%. PHDC data show a slow but steady increase in provincial HIV prevalence from 16.7% in 2015 to 18.6% in 2020. The highest HIV prevalence was in the Cape Metro district (20.3%) Prevalence estimates by age group were comparable between sentinel surveys and PHDC from 2015 onwards, with prevalence estimates stable over time among younger age-groups (15\u0026ndash;24 years) but increased among older age-groups (\u0026gt;\u0026thinsp;34 years).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study compares sentinel seroprevalence surveys with both register-based aggregate data and consolidated individuated administrative data. We show that in this setting linked individuated data may be reliably used for HIV surveillance and provide more granular estimates with greater efficiency than seroprevalence surveys and register-based aggregate data.\u003c/p\u003e","manuscriptTitle":"Exploring the validity of routine individuated service data for antenatal HIV surveillance in the Western Cape","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-21 16:35:30","doi":"10.21203/rs.3.rs-4065819/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-19T05:49:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-18T13:32:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-18T13:32:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-03-10T14:43:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2f45f29e-d8ac-4c73-a8f8-25dac885c9fd","owner":[],"postedDate":"March 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-10T19:45:41+00:00","versionOfRecord":{"articleIdentity":"rs-4065819","link":"https://doi.org/10.1186/s12879-025-10639-6","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2025-03-04 15:57:59","publishedOnDateReadable":"March 4th, 2025"},"versionCreatedAt":"2024-03-21 16:35:30","video":"","vorDoi":"10.1186/s12879-025-10639-6","vorDoiUrl":"https://doi.org/10.1186/s12879-025-10639-6","workflowStages":[]},"version":"v1","identity":"rs-4065819","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4065819","identity":"rs-4065819","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}