Page 20 - HIVMED_v21_i1.indb

Page 2 of 8 Guideline

Whilst the achievements in reducing HIV transmission at suppressive ART during antenatal care, the risk of MTCT is
birth are noteworthy, the Global Plan target of elimination of reduced by 10%. Therefore, the prescription of antiretroviral
1
2
vertical transmission will remain elusive due to SA’s high drugs that rapidly and safely achieve and sustain maternal
HIV prevalence rates. This brings into stark focus the need viral suppression during pregnancy and the breastfeeding
for primary prevention of HIV in all women of reproductive period is of greatest importance to the prevention of vertical
potential, before, during, and after pregnancy, as well as the transmission. In this regard, the newly introduced integrase
urgent need to intensify measures to prevent unintended inhibitor dolutegravir (DTG) offers improved tolerability,
pregnancies. few drug interactions, and the reduced risk of viral drug
resistance. The time to viral suppression is approximately
18
According to data published in 2016, the cumulative vertical halved by DTG when compared to the currently administered
transmission rate by 18 months of age is 4.3%. The largest drug efavirenz (EFV). 18
8
proportion (> 80%) of these transmissions occur during
the first six months of the breastfeeding period, when women Recent data from Botswana indicates that DTG may increase
8
may experience pronounced challenges to adherence the risk of neural tube defects (NTDs). The absolute risk is
19
and retention in care, impacting negatively on viral low, currently documented at 0.3% for mothers conceiving
suppression. 9,10,11,12 At the same time, breastfeeding remains a on a DTG-containing ART compared to a risk of 0.1% for
key strategy to ensure that South African children survive and mothers conceiving on alternative regimens. Whilst the
20
thrive. The evidence indicates that the benefits of breastfeeding World Health Organization (WHO) has recommended DTG
outweigh the risks of not breastfeeding, regardless of the as the preferred first-line option for all populations (weight ≥
maternal HIV status. 13,14,15 As the HIV epidemic matures, it is 20 kg) without exceptions, South Africa has opted for a more
clear that the breastfeeding period must be one of the main conservative approach, and recommends that DTG should
priorities in the prevention of vertical transmission of HIV. be used with caution in women wanting to conceive, and be
New innovative strategies are required to achieve and avoided in the first six weeks of pregnancy, that is, following
maintain maternal viral suppression in the period after birth, her last menstrual period and before closure of the foetal
whilst simultaneously promoting breastfeeding as a major neural tube approximately four weeks after conception.
child survival strategy. In addition, sustained maternal viral However, recent evidence indicates that DTG is likely to
suppression will allow the realisation of the longer-term have health and cost benefits over EFV even in women who
advantages of ‘Option B Plus,’ including improved maternal intend pregnancy, providing further confirmation for the
21
health, viral suppression in subsequent pregnancies, and WHO’s more inclusive approach. Whilst South Africa’s
reduced HIV transmission to sexual partners. position on DTG is likely to change as evidence evolves,
confusion around the use of DTG in women of childbearing
To this end, the South African Department of Health has potential has resulted in the suboptimal uptake of effective
revised the Guideline for the Prevention of Mother to Child ART in the women who need it most.
Transmission of Communicable Infections (2019). This
standalone guideline also forms part of the revised National As a positive consequence, the current DTG recommendations
Consolidated Guidelines for the Management of HIV in will require that family planning services be better integrated
Adults, Adolescents, Children and Infants and for the into ART care. Health care workers should regularly discuss
Prevention of Mother-to-Child Transmission (2019). The issues of childbearing and contraception with their clients in
guideline incorporates new evidence, both scientific and order to understand current fertility intentions and
operational, to ensure that South Africa’s HIV PMTCT contraceptive needs. All women require appropriate
programme remains relevant, practical, and evidence-based. counselling on the risks and benefits of DTG and should make
A concerted effort has been made to ensure alignment between an informed choice (Box 1). Women may choose to use DTG;
these guidelines and other national guidelines, including the for those women who choose not to use DTG, EFV remains a
Standard Treatment Guidelines and Essential Medicines List safe, efficacious and cost-effective option. Concurrent use of
for South Africa. It includes a strong focus on the prevention effective contraception is recommended for all non-pregnant
of HIV and unintended pregnancies in women of childbearing women not currently desiring a pregnancy.
potential, maternal viral suppression, preventing MTCT
during the breastfeeding period, and care integration for the
mother-infant pair. A summary of the major changes in the Regimen switches during pregnancy
guideline is illustrated in Table 1, together with the rationale A single drug switch from an EFV-containing regimen to a
for major changes for WLWH, being provided in the text. DTG-containing regimen should only be considered if the
client has a suppressed VL (in the last six months), irrespective
Specific guidelines changes of pregnancy status. Therefore, pregnant women already on
Antiretroviral therapy during pregnancy and the ART should continue their current ART regimen, pending
the result of their HIV VL at entry into antenatal care. If the
breastfeeding period VL is below 50 copies/mL, and the woman has progressed
The risk of vertical HIV-transmission correlates strongly with past the initial six weeks of pregnancy, that is, six weeks since
maternal HIV VL levels. 16,17 For every additional week on her last normal menstruation, switching to a DTG-containing

http://www.sajhivmed.org.za 12 Open Access