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likelihood of a mycobacterial infection (OR 2.11, 95% HIV-negative pregnant women unexposed to ARVs, first-
CI 1.28–4.41, p = 0.005). ‘Unique’ diagnoses mean diagnoses trimester exposure to efavirenz in HIV-positive women did
found only on BMAT despite extensive alternate investigation not increase the risk of CM (risk ratio [RR] 0.87, 95% CI 0.12–
or achieved before the results of other tests were available or 6.4, p = 0.895). However, first-trimester NVP exposure may
known. Unique diagnoses occurred in 77 (23.5%) patients increase the risk: RR 9.2, 95% CI 2.27–37.94, p = 0.002. This
and were Mycobacterium tuberculosis (MTB) in 17/77 (22%) finding may have been influenced by confounders (e.g. small
and Mycobacterium avium complex (MAC) in another three numbers) and thus requires more data or confirmation. The
patients. Three BMATs each provided ≥ 1X ‘unique’ diagnosis, risk of ABOs was greater in infants of mothers with exposure
for example, TB and cancer. Proven or suspected mycobacterial to ART at any time throughout pregnancy versus HIV-
disease accounted for 57 BMATs with granulomas, culture- uninfected mothers (RR 1.23, 95% CI 1.14–1.31, p < 0.001) but
proven MTB without supportive histology in 50 and MTB particularly where EFV or NVP use had started before the
confirmed with granulomas in 32 patients. The limitations of pregnancy. This report is published at a time when guidelines
this study include its retrospective format, inherent case are changing. The non-nucleoside reverse transcriptase
selection bias and, sadly, the absence of newer diagnostic inhibitors (NNRTIs) are being phased out of first-line
tools such as sputum and urine MTB-rif-resistance gene- regimens. But women unable to take DTG are likely to be
Xpert, gene-XPert Ultra and urine lipoarabinomannan given EFV or perhaps NVP. This is a high-end paper that is
(LAM). The latter is particularly disappointing as these informative and supports the long-term role of EFV in
molecular diagnostics are currently changing the face of women for whom DTG is contraindicated.
clinical medicine.
13. Mehta UC, Van Schalkwyk C, Naidoo P, et al. Birth Suggested additional reading
outcomes following antiretroviral exposure during
pregnancy: Initial results from a pregnancy exposure • Zash R, Holmes L, Diseko M, et al. Neural tube defects
registry in South Africa. S Afr J HIV Med. 2019;20(1):a971. and antiretroviral treatment regimens in Botswana. N
https://doi/org/10.4102/sajhivmed.v20i1.971 Eng J Med. 2019 Aug;381(9):827–840. https://doi.
org/10.1056/NEJMoa1905230
Editor’s comment: Recommended reading. Although • The National Department of Health, The Republic of
international first-line ART guidelines have replaced South Africa. 2019 antiretroviral treatment guidelines for
nevirapine (NVP) and efavirenz (EFV) with dolutegravir the management of HIV in adults, pregnancy, adolescents,
(DTG), concerns remain regarding the safety of ART in children, infants and neonates. October 2019. Dolutegravir
pregnancy. Dolutegravir is teratogenic in the first trimester of Overview, ART Initiation, p. 8. Available from: https://
pregnancy. Women living with HIV and planning a family www.health.gov.za
and those diagnosed with HIV in the first trimester should
not use DTG. This article addresses the safety of NVP and October 2019
EFV in pregnancy in a cohort of pregnant South African (SA) 14. Cele MA, Archary M. Acceptability of short text messages
women. to support treatment adherence among adolescents living
with HIV in a rural and urban clinic in KwaZulu-Natal. S
In 2013, the SA National Department of Health promoted the Afr J HIV Med. 2019;20(1):a976. https://doi.org/10.4102/
introduction of a birth-outcomes registry amongst pregnant sajhivmed.v20i1.976
women and their infants exposed to ARVs. The authors
report on the first 12 months of this programme (2013–2014). Editor’s comment: This article reports the results of a small,
Two outcomes were assessed: questionnaire-based, cross-sectional, pilot study of 100
adolescents (aged 12–19 years) from two clinic sites – one
1. Major congenital malformations (CMs) following ARV
exposure in the first trimester of pregnancy. urban (n = 50) and the other rural (n = 50) in KwaZulu-Natal,
2. Adverse birth outcomes (ABOs), namely, foetal death, South Africa. Poor retention in care and unreliable treatment
preterm delivery, low birth weight, small for gestational adherence challenge the success of antiretroviral therapy
age and neonatal death, following ARV exposure at any (ART) in this group of patients. Will text messaging remedy
time during pregnancy. the problem? The authors confirm the widespread use (88%)
of mobile devices amongst rural and urban respondents.
Data were collected at the Prince Mshiyeni Memorial Although two-thirds of participants were willing to receive
Hospital in Umlazi, Durban, South Africa. A total of 10 417 their health information messages through mobile devices,
pregnancies and 10 517 birth outcomes were captured. The others were unwilling or undecided. Higher education was
overall prevalence of HIV infection was 4013/10 417 (38.5%). found to be linked with greater mobile device usage. But who
A higher prevalence was noted in women > 35 years are those – people living with HIV – who are unwilling or
(640/1100; 58%) and in multigravida versus primigravid undecided? Did the potential breach of privacy and the risk
women (49.2% vs. 21.9%), respectively. The numbers of major of unsanctioned disclosure via their smartphone inform the
CMs were small. About one-third of cases were in infants of negative response? Forty-eight per cent of the cohort had
mothers who were on ART (11/27; 29.7%). Compared to never sent health-related short message services (SMSs) to or

http://www.sajhivmed.org.za 7 Open Access