HIV prevalence in South Sudan: data from the ANC sentinel surveillance 2009

Summary

Data on the prevalence of HIV and syphilis was collected from 24 ante-natal care clinic (ANC) sentinel sites in all 10 states of South Sudan during the three months September to December 2009. The overall sample size was 6175 pregnant women, however only 5913 samples were tested for HIV of which 176 (3%) were positive.

Interestingly, the age groups 15-24 years accounted for almost half (49.5%) of the overall sample size of this ANC 2009 Survey distributed between the age group 15-19 years with 18.6% of the overall sample and the age group 20-24 years accounting for 30.9% of the total sample size. 

The prevalence of HIV was 2.3% (n=25) in the 15-19 year age group and 3.3% (n=59) in the 20-24 year age group. The prevalence of syphilis was 7.6% (n=74) in the 15-19 year age group and 9.6% (n=183) in the 20-24 year age group.

The HIV prevalence among the young women aged 15-24 years was 2.9% compared to the overall HIV prevalence among all age groups of 3%. Similarly the syphilis prevalence among 15-24 year old women was 28.4% compared to the overall survey syphilis prevalence of 9.9%.

In conclusion, the post conflict ANC surveillance showed an HIV prevalence of 3% and the experience has proved and disregarded a wide range of assumptions with regards to HIV distribution in the country. Despite all challenges, the routine ANC surveillance system, in the context of South Sudan,  is very promising in provision of timely relevant information and can be used to monitor the trend over time.

Introduction

Although the prevalence of HIV was estimated from 2007 data at only 3.1%1, the Ministry of Health decided to set up a surveillance system to periodically monitor the prevalence and trends of HIV/AIDS.

Data from South Sudan and other studies show that periodic estimates for HIV prevalence for pregnant women represent a suitable monitor to HIV trends overtime. However it often overestimates the general population prevalence. For this reason other studies should be conducted, triangulated and corroborated with it. The MOH has implemented the Second Sudan Household Health Survey (SHHS II); it is expected that the results will produce representative population based estimates for HIV in South Sudan with which data from ANC surveillance surveys will be corroborated.

With the signing of the Comprehensive Peace Agreement (CPA) in January 2005, 22 years of civil war in South Sudan officially ended. Since then the focus of health planning has shifted from relief to development.  Even so the war, which has greatly affected South Sudan, left all segments of the population still facing formidable social problems including health related challenges such as HIV/AIDS. 

The return of refugees from surrounding countries with higher HIV prevalence has increased the risk of HIV infection in South Sudan.  High risk behaviours resulting from poverty and certain cultural practices of different communities including returnees and people from neighbouring countries, and high incidences of STIs aggravated by poor access to and/or low coverage of health services further contribute to the spread of the HIV. However, knowledge of prevention methods and where to get help is a critical first step towards addressing some of these key drivers.

Other effects of peace are increased trade and commercial activities across borders (especially increased traffic of trucks and other vehicles along the trans-African Highway), reconstruction and rehabilitation activities, relative peace and affluence coupled with cultural religious and tribal traditions all of which may contribute to the risk of HIV in the post war era.

HIV situation in South Sudan

Previous ANC sentinel surveillance results covering 10 sites in 6 states of South Sudan indicated that 3.8% of the 3,638 tested were found to be reactive by EIA (ELISA) with a range in prevalence of 0% - 12% (1). Surveys conducted in Yei (2002) and Rumbek (2003) also showed huge regional differences (2). While Rumbek had 0.4% sero-prevalence, Yei recorded 2.7%. In 2000, a sleeping sickness survey in Tambura, Ezo and Yambio counties tested 500 people for HIV and found that:

  • 1.6% tested positive in Tambura and 2% in Ezo.
  • Villages near the road had a higher prevalence (3.2%) compared with those further from it (1.1%).  Yambio had the highest rate (7.2%), which ranged from 3% in peri-urban areas to 8.7 percent in Yambio town.

The Sudan Household Survey Report 2006 (3) indicated that the level of knowledge of how to prevent HIV transmission was staggeringly low among women aged 15-49 years in most States (i.e. 36% in Lakes, 8.9% in Jonglei and 9.7% in Warrap). However it was 64% in Central Equatoria.

MSF-Switzerland (4) reported in 2006 that the prevalence among blood donors ranged from 11% in Kajo Keji to 0% in the fairly remote areas of Bahr el Ghazal. Yei is reported to have prevalence rates among some formally displaced adults of 4.4%. Although limited in coverage, the ANC surveillance and the Yei/Rumbek surveys are considered to have provided key findings that informed the HIV situation in South Sudan before the ANC surveillance in 2009. They indicated that:

  • HIV rates vary widely between different States.
  • Rates may be higher where there has been greater population mobility and contact with other countries.
  • Rates appear to be higher in towns than in rural areas.
  • Rates in women are markedly higher than those in men.

Compared to Rumbek, more participants in Yei had been displaced internally or as refugees but a history of displacement were not significantly associated with HIV status.

Objectives

The overall objective of establishing ANC sentinel surveillance sites is to provide data for estimating HIV prevalence and so monitor the epidemic in different regions and overtime.

The specific objectives are to:

  1. Monitor the trends of HIV (and syphilis infection) among pregnant women attending ANC sentinel sites
  2. Provide estimates of the burden and distribution of HIV infection in the general population at least in areas where the surveillance is conducted, by extrapolating data from prevalence in pregnant women attending ANC clinics.
  3. Support dissemination of sentinel surveillance information in order to advocate and plan more effective HIV prevention and control services.
  4. Establish a review process for ANC surveillance data, triangulated with data from other sources that will achieve informed consensus about population prevalence.

Methodology

Selection of sample

Sentinel surveillance was conducted among pregnant women aged 15-49 attending ANC. Pregnant women were selected as a proxy for the general population and because they represent the sexually active population. Women recruitment in the survey depended on whether they were on their first ANC visit to the sentinel clinic for that pregnancy or the visit when blood testing was first done. They also had to be residents of the site’s catchment area and to have attended the clinic during the sentinel surveillance period.

Each eligible woman was enrolled until the required sample size was attained or the sampling period ended. The sample size was pre-determined for each site as:

  • Urban - 300 pregnant women/site in 14 sites.
  • Rural - 250 pregnant women/site in 10 sites.

Selection of sentinel sites

It was impractical to have a site in all 79 counties. Potential sites were assessed based on: numbers attending in the previous three months, level of laboratory services and personnel, and ability to store and ship specimens. This resulted in the selection of 24 sites with at least one from each State - see Table 1.

Table 1. Ante-Natal Care (ANC) Sites for HIV Sentinel Surveillance 2009

State

Urban

Rural

Central Equatoria

Juba Teaching Hospital (JTH)

Nyakuron PHCC

Kajo Keji Hospital St.Bakita - Yei

Unity

Bentiu State Hospital

Leer-MSF Holland

Western Bahr El Ghazal

Wau Teaching Hospital

None

Western Equatoria

Yambio Civil Hospital

Tambura PHCC- IMC                                    Maridi

Upper Nile

Malakia PHCC

Bam PHCC                                    Malakal Teaching Hospital

Renk Civil Hospital

Lakes

Rumbek State Hospital                Rumbek PHCC

Cueibet PHCC

Eastern Equatoria

Torit Civil Hospital

Nimule Hospital –Merlin

Jonglei

Bor Civil Hospital

Boma Hospital-Merlin                  Akobo PHCCs –IMC

Northern Bahr El Ghazal

Awiel Hospital

None

Warrap

Kwajok Hospital

None

Total

14

10

Recruitment and training

Fifty eight laboratory technicians, nurses/midwives, and field supervisors were trained for 4 days.  Nurses and midwives were trained how to:

  • identify eligible clients
  • fill in laboratory request forms and
  • refer clients to the laboratory for routine haemoglobin and syphilis tests.

Field laboratory technicians were trained how to:

  • collect blood samples
  • prepare, package and store dried blood Spot (DBS) and
  • transport them to the JTH laboratory.

Training emphasized ways to minimize risks in handling biological specimens and gave an overview of HIV/AIDS. Three laboratory technologists from JTH were trained for two weeks on DBS ELISA testing in Nairobi.

Sample collection

3-5ml of blood was taken from the arm by venepuncture using the vacutainer system, put into a purple EDTA anticoagulated tubes and mixed well. Prior to testing any identifiers on the samples were removed and replaced with pre-printed 8-digit surveillance code label. Demographic information was transferred from the laboratory request form to the surveillance form. Each day, a drop from the left over blood was placed on the three circles of the S & S 903 filter paper. The DBS filter papers were dried overnight, packaged according to the Standard Operating Procedures and shipped to JTH laboratory every two to three weeks.

Site supervision

Ten supervisors from MOH Directorate of HIV/AIDS/STIs and South Sudan AIDS Commission (SSAC) visited each site at least once a month to:

  • perform quality checks on demographic data collection  and field laboratory procedures
  • deliver supplies and
  • take the data collection forms and DBS samples to the JTH laboratory.

Sample processing

The JTH coordinated all the laboratory logistics including securing and storage of supplies for the field laboratory activities, receiving, archiving and processing samples, testing, coordinating with the CDC quality assurance laboratory and dispatch of results to MOH Directorate of HIV/AIDS/STIs.

At JTH, laboratory staff checked the integrity of the samples and that they were accompanied by the surveillance forms. 95.77% of the DBS submitted were of adequate quality for testing. These were logged on a spread sheet and stored at -20ºC.

All the eligible samples were initially tested for HIV using Vironostika uniform II plus O ELISA kit. Quality control was done at JTH following the standard operating procedures and using known DBS controls. Results of HIV were crosschecked to ensure accuracy.  All the reactive samples and 5% of randomly selected non-reactive samples were retested for quality assurance at the CDC laboratory in Kenya using the Murex HIV antibody kit. Specimens with discrepant results between the two laboratories were retested again at the CDC laboratory using the same algorithm. Specimens that were still discrepant after retesting were resolved by PCR at CDC QA lab.

Data analysis

Demographic data were entered in a spread sheet in the HIV Directorate and sample information was entered in JTH laboratory. All sheets were locked and computers were pass-worded protected. Data were analyzed using SPSS version 17.0. The standard formula for statistical methods (5) (6) was used to calculate the confidence interval for the observed prevalence for each site based on the sample size collected. It provides information on the relationship between surveillance sample sizes and statistical confidence intervals, for different HIV prevalence rates.

Results

Characteristics of the respondents

A total of 6175 pregnant women were recruited (see Table 2). Table 3 shows that 50% of respondents were aged 15- 24 years. 93.5% were married (60% in monogamous marriages and 33% in polygamous ones).

Table 2. Distribution of respondents by State 

State

Number

Percent

Central Equatoria

1119

18.1

Eastern Equatoria

552

8.9

Jonglie

630

10.2

Lakes

899

14.6

Northern Bahr El Ghazal

300

4.9

Unity

441

7.1

Upper Nile

807

13.1

Warrap

300

4.9

Western Bahr El Ghazal

299

4.8

Western Equatoria

828

13.4

Total

6175

100

Table 3. Distribution of respondents by age 

Age years

Number

Percent

15 - 19

1151

18.6

20 - 24

1905

30.9

25 - 29

1662

26.9

30 - 34

895

14.5

35 - 39

481

7.8

40 - 44

45

0.7

45 - 49

34

0.6

Missing data

2

0.0

Total

6175

100.0

Prevalence of HIV

The HIV test was carried out on samples of only 5913 of the 6175 women recruited. 176 (3%) of these 5913 women were positive for HIV. However prevalence varied widely among the sites and States ranging from 7.2% in Western Equatoria to 0% in Northern Bahr El Ghazal. – see Figures 1 and 2.

 

Figure 1. HIV prevalence by site

 

Figure 2. HIV prevalence by State

HIV Results by age, site and state

The distribution of HIV results by ANC site is shown in Table 4. Meanwhile, Table 5 shows the sample size and the HIV prevalence in the different states. Table 6 show the age distribution of the HIV-positive women.

Table 4. HIV results by ANC site

 

 

Total Tested

Result

S/N

Site Name

 

Positive (%)

Negative

1

Akobo PHCC

169

1 (0.6%)

168

2

Aweil Civil Hospital

299

0 (0.0%)

299

3

Bam PHCC

169

6 (3.6%)

163

4

Bentiu State Hospital

296

4 (1.4%)

292

5

Boma PHCC

159

4 (2.5%)

155

6

Bor Civil Hospital

300

8 (2.7%)

292

7

Cueibet PHCC

300

1 (0.3%)

299

8

Juba Teaching Hospital

299

18 (6.0%)

281

9

Kajokeji Civil Hospital

264

6 (2.3%)

258

10

Kuajok PHCC

289

2 (0.7%)

287

11

Leer PHCC

135

3 (2.2%)

132

12

Malakal Teaching  Hospital

265

8 (3.0%)

257

13

Malakia PHCC

140

5 (3.6%)

135

14

Maridi PHCC

250

6 (2.4%)

244

15

Nimule PHCC

249

14 (5.6%)

235

16

Nyakuron PHCC

300

12 (4.0%)

288

17

Renk Civil Hospital

216

2 (0.9%)

214

18

Rumbek  State Hospital

283

16 (5.7%)

267

19

Rumbek PHCC

300

5 (1.7%)

295

20

St. Bakhita PHCC

255

8 (3.1%)

247

21

Tambura PHCC

250

19 (7.6%)

231

22

Torit  Civil Hospital

298

4 (1.3%)

294

23

Wau Teaching Hospital

299

4 (1.3%)

295

24

Yambio Hospital

129

20 (15.5%)

109

 

Total

5913

176 (3.0%)

5737

Table 5. HIV results by State

S/N

State

Total Tested

Number Positive (%)

Negative

1

Central Equatoria State (CES)

1118

44 (3.9%)

1074

2

Eastern Equatoria State (EES)

547

18 (3.3%)

529

3

Jonglei State

628

13 (2.1%)

615

4

Lakes State

883

22 (2.5%)

861

5

Northern Bahr Ghazal State (NB)

299

0 (0.0%)

299

6

Unity State

431

7 (1.6%)

424

7

Upper Nile State (UN)

790

21 (2.7%)

769

8

Warrap State

289

2 (0.7%)

287

9

Western Bahr Ghazal State (WB)

299

4 (1.3%)

295

10

Western Equatoria State (WES)

629

45 (7.2%)

584

 

Total

5913

176 (3.0%)

5737

 Table 6. Distribution of HIV results by age group

 

Age group

 

Total tested

HIV positive

 

Number

%

15 – 19

1091

25

2.3

20 – 24

1811

59

3.3

25 – 29

1605

51

3.2

30 – 34

858

29

3.4

35 – 39

468

11

2.4

40 – 44

44

1

2.3

45 – 49

34

0

0.0

Missing data

2

0

0.0

Total

5913

176

3.0

Syphilis Results among HIV positive Clients

Of the 176 HIV positive pregnant women, 27 were found to be reactive for syphilis accounting for a prevalence of 15.3% among HIV Positive clients. (Table 7)

Table 7. Distribution of syphilis results among HIV positive clients by site.

 

Site

Syphilis Test

Total

Non Reactive

Reactive

Akobo

1

0

1

Bam PHC

6

0

6

Bentiu

3

1

4

Boma

4

0

4

Bor H

6

2

8

Cueibet

0

1

1

JTH

17

1

18

Kajokeji

5

1

6

Kuajok

2

0

2

Leer

3

0

3

Malakal H

6

2

8

Malakia PHC

4

1

5

Maridi

6

0

6

Nimule

13

1

14

Nyakuron

11

1

12

Renk

1

1

2

Rumbek  H

10

6

16

Rumbek PHC

2

3

5

St. Bakhita

8

0

8

Tambura

16

3

19

Torit H

4

0

4

Wau

4

0

4

Yambio

17

3

20

Total

149

27

176

HIV and syphilis among young women aged 15-24 years

The distribution of HIV and syphilis among HIV positive young women were as shown in Table.8

Table 8. Prevalence of HIV and syphilis among young women 15-19 and 19-24 years

Age Group 

Total

Percentage Distribution

Cumulative Distribution

 

15 - 19

1151

18.6

18.64

 

20 - 24

1905

30.9

49.49

 

HIV   

Total

Positive

Negative

%(15-24 years)

% Total

15-24

2902

84 (2.9%)

2818

2.9

3.0

15 - 19

1091

25 (2.3%)

1066

 

 

20 - 24

1811

59 (3.3%)

1752

 

 

Syphilis 

Total

Positive

Negative

%(15-24 years)

% Total

15-24

3056

257

(8.4%)

2799

8.4

9.9

15 – 19 

1151

74

(6.4%)

1077

 

 

20 – 24 

1905

183

(9.6%)

1722

 

 

As above, the prevalence of HIV was:

  • 2.3% (n=25) in the 15-19 year age group and
  • 3.3% (n=59) in the 20-24 year age group.

The prevalence of syphilis was:

  • 7.6% (n=74) in the) in the 15-19 year age group and
  • 9.6% (n=183) in the 20-24 year age group.

Discussion

The overall objective of establishing ANC sentinel surveillance system in South Sudan is to provide data for monitoring the epidemic in different regions of South Sudan over-time in addition to estimating HIV prevalence. Although South Sudan has conducted only two rounds of ANC Surveillance, an attempt has been made to compare and track the prevalence in the different sites taking into account the increasing number of sites in the subsequent round  see Table 9.

Table 9. Comparison of HIV numbers and prevalence in the 2007 and 2009 surveys

 Site Name

Number tested 2007

Number HIV Positive (%) 2007

95% Confidence Interval

Number tested 2009

Number HIV Positive (%) 2009

95% Confidence Interval

(U- urban; R – rural)

Awiel Civic Hospital (U)

---

---

---

299

0 (0.0%)

---

Cuiebet PHCC (R)

107

1 (0.9%)

0.02 - 5.1%

300

1 (0.3%)

0 – 0.98%

Akobo PHCC (R)

110

1 (0.9%)

0.02 - 5%

169

1 (0.6%)

0 –  0.7%

Kuajok PHCC (U)

---

---

---

289

2 (0.7%)

0 – 1.6%

Renk Civic Hospital (R)

---

---

---

216

2 (0.9%)

0 – 2.2%

Torit Civic Hospital (U)

---

---

---

298

4 (1.3%)

.03 – 2.7%

Wau Teaching Hospital(U)

---

---

---

299

4 (1.3%)

.04 - 2.6%

Bentiu State Hospital (U)

---

---

---

296

4 (1.4%)

.04 - 2.7%

Rumbek PHCC (U)

---

---

---

300

5 (1.7%)

0.2 - 3.1%

Leer – PHCC (R)

874

7 (0.8%)

0.3 – 1.6%

135

3 (2.2%)

0 - 4.7%

Kajo Keji Civil Hospital (R)

1045

17 (1.6%)

1.0 - 2.6%

264

6 (2.3%)

0.5 – 4.1%

Maridi PHCC (R)

244

14 (5.7%)

3.2 - 9.4%

250

6 (2.4%)

0.5 – 4.3%

Boma PHCC (R)

429

31 (7.2%)

5.0 - 10.1%

159

4 (2.5%)

.08 – 5.0%

Bor Civil Hospital (U)

---

---

---

300

8 (2.7%)

0.9 – 4.5%

Malakal Hospital(U)

---

---

---

265

8 (3.0%)

1.0 – 5.1%

St. Bakhitia PHCC (R)

792

21(2.7%)

1.6 - 4.0%

255

8 (3.1%)

1.0 – 5.3%

Malakia PHCC  (U)

---

---

---

140

5 (3.6%)

0.5 – 6.6%

Bam PHCC (U)

---

---

---

169

6 (3.6%)

0.8 – 6.3%

Nyakuron PHCC (U)

---

---

---

300

12 (4.0%)

1.8 – 6.2%

Nimule PHCC (R)

492

11 (2.2%)

1.1 - 4.0%

249

14 (5.6%)

2.8 – 8.5%

Rumbek State Hospital (U)

---

---

---

283

16 (5.7%)

1.0 – 8.3%

Juba Teaching Hospital (U)

---

---

---

299

18 (6.0%)

3.3 – 8.7%

Pochalla PHCC

18

2 (11.1%)

*

---

----

 

Tambura PHCC (R)

599

69 (11.5%)

9.1 - 14.4%

250

19 (7.6%)

4.3 – 10.9%

Yambio Hospital (U)

---

---

---

129

20 (15.5%)

9.3 – 21.8%

Total

4,710

174 (3.7%)

3.2-4.3%

5,913

176 (3.0%)

2.6 – 3.4

Although the ANC surveillance provides results by sites, an aggregate by South Sudanese states was produced to inform and educate the different levels of local government in each state i.e. State, Counties and Payams.  HIV results ranged from as high as 7.2% in Western Equatoria state to as low as no sero-positivity (0%) in Northern Bahr El Ghazal state. The sample sizes varied from one state to another according to the number of sites contributed to the survey.

Interestingly, the age group 15-24 years accounted for almost half (49.5%) of the overall sample size of this ANC 2009 survey. Within the overall sample 18.6% were in the 15-19 year age group and 30.9% in the 20-24 year age group.

The HIV prevalence among the young women aged 15-24 years was 2.9% compared to the overall HIV prevalence among all age groups of 3% - see Figure 3. Similarly the syphilis prevalence among 15-24 year old women was 28.4% compared to the overall survey syphilis prevalence of 9.9% - see Table 8.

In conclusion, the post conflict ANC surveillance experience in South Sudan has proved and disregarded a wide range of assumptions with regards to HIV distribution in the country. Despite all challenges, the routine ANC surveillance system, in the context of South Sudan,  is very promising in providing timely relevant information and can be used to monitor the trend over time.

Recommendations

For Programmes

  1. Strengthen Social Mobilization Campaigns in the communities to enhance uptake of ANC services especially during the sentinel surveillance periods.
  2. Increase the reach of HIV prevention, treatment and care in areas where the prevalence is merely high.

For Surveillance

  1. New sites may be considered as follows: data from population surveys and/or PMCT indicate that existing sites do not adequately or appropriately represent segments of the population. Population reassignments may also be made based on new information from complementary sources
  2. Identify additional sites in the same geographical area (e.g. Yambio, Akobo etc…) where the desired sample size was not attained. And combine multiple sites to form one composite site for that geographical location. (Use all available date including VCT, PMTCT, ART to identify potential locations).
  3. Increase surveillance sites to at least in one in each county in states where HIV prevalence has been highly detected like Western Equatoria State.
  4. Involve NGO in planning and identification of new sites and implementation of the surveys. (One NGO running an ANC site was not initially cooperative in allowing the survey process in that specific location. This resulted in a delayed start and low sample attainment).
  5. Ensure the availability of STI drugs, and other supplies in all Sentinel Surveillance sites during the sentinel surveillance period
  6. Ensure that all logistic are in place in subsequent rounds to avoid another major rejection of samples (262 samples were rejected due to improper packaging (26), missing (25), contamination (4) and improper sample preparation (3). Due to rain Yambio and Maridi were inaccessible in the first month of data collection so 199 samples had exceeded the allowed storage time at room temperature when they reached JTH). This will save a lot of energy, time, and resource and eventually increase precision of the results.

For Research

  1. Compare the upcoming SHHS II results to the ANC surveillance results to obtain a more accurate national estimate.
  2. More behavioural and biological research is recommended in areas where the prevalence appeared to be low to further complement the current results.  

Limitations of the study

  • ANC surveillance only accounts for women, and specifically women who attend the ANC, so there is a bias towards those who have access to the service.
  • Some States have only one ANC site while others go up to 4 sites making a difference in the sample size per state; as a result further weighting can be calculated to precise the prevalence by state.
  • Although the study provided valuable biological indicators for HIV and syphilis, no behavioural information was generated and linked to the biological aspect in this study.

Footnotes:

  1. Based on calculations done by the South Sudan AIDS Commission in 2007. Derived from the 2007 ANC Surveillance conducted by US-CDC.

References:

  1. ANC surveillance Report, US-CDC (2005 – 2007) – Unpublished
  2. 2.     Population –based surveys, US-CDC, (2002 – 2003) – Unpublished
  3. Sudan Household Health Survey, 2006, Ministry of Health, South Sudan
  4. Kaiser R, Kedamo T, Lane J, Kessia G, Downing R, Handzel T, Marum E, Salama P, Mermin J, Brady W, Spiegel P. “HIV, syphilis, herpes simplex virus 2, and behavioural surveillance among conflict-affected populations in Yei and Rumbek, southern Sudan.” AIDS 2006 Apr 4;20(6):942-44.
  5. Fleiss, J. L. Statistical methods for rates and proportions. 2nd ed. New York: John Wiley pp. 38–46, 1981
  6. Snedecor G. W. & Cochran W. G. Statistical methods 6th ed. Iowa: Iowa State University Press, USA, 1967.

Acknowledgement

Dr. Lul P. Riek Director General for HIV Directorate Ministry of Health for the strong leadership, guidance & commitment expressed.  Mr. Gregory Wani, the laboratory focal person and his team in Juba Teaching HospitalMs. Elizabeth Novello Nylock, HIV/AIDS/STIS Surveillance officer for the extensive coordination and logistical support she provided during the trainings and the data collection. The ten States’ Ministries of Health and states HIV/AIDS/STIs Directors/Coordinators for providing direct support and supervision of data collection from the facilities. I would also like to acknowledge the quality of samples collected during the ANC surveillance survey 2009, and this goes to the laboratory staff in the 24 health facilities undertaken this survey round. For data entry Mr Eban Taban, Senior HIV/AIDS/ STIs Monitoring and Evaluation Specialist,  Ms Idak Makur VCT Counselor and Ms. Golda Caeser, Surveillance officer.  Dr. Emmanuel Lino, Deputy Director for HIV Clinical Management & Care, Mr. James Ayeiny, HIV/AIDS/STIS Surveillance officer. NGOs running the health facilities during this ANC surveillance survey 2009. Great Acknowledgment goes to Dr. Fazle Khan and Mr. Edwin Ochieng of CDC for the specialized technical, logistical support and quality assurance of the survey.  Dr. Oivia Lomoro, the Undersecretary of the Ministry of Health for the political commitment and overall support. We register our acknowledgement to the Global Fund for making this survey a reality in the history of South Sudan.