Page 349 - HIVMED_v21_i1.indb

Page 3 of 7 Original Research

TABLE 1: Evolution of the South African prevention of mother-to-child transmission and antiretroviral therapy guidelines, 2002–2015. 18,19,20,21,23,24
2002 2004 2008 2010 2012 2013 2015
PMTCT Intrapartum Intrapartum Option A – Integration of ART Withdrawal of free Option B – triple therapy Option
guidelines single-dose single-dose NVP zidovudine initiation within infant formula for for all PWLHIV, with B+ – lifelong ART
NVP monotherapy for antenatal clinics WLHIV who elect postpartum withdrawal for all PWLHIV,
PMTCT, for not to breastfeed of therapy in those not regardless of level
pregnant women eligible for lifelong of immune
not eligible for treatment suppression
lifelong treatment
Infant Single-dose Single-dose NVP 7 days of AZT, or 6 weeks of NVP and - 6 weeks of NVP and 6 weeks NVP and
prophylaxis NVP after after birth 28 days if the extended for the extended for the extended to 12
birth mother received duration duration of weeks if infant at
less than 4 weeks of breastfeeding if breastfeeding if high risk of MTCT†
of AZT or ART mother not on ART mother not on ART
ART - Triple therapy Triple therapy ART eligibility criteria for ART eligibility ART eligibility criteria for ART for all PWLHIV,
guidelines Eligibility criteria: Eligibility criteria: pregnant women: CD4 ≤ criteria for pregnant pregnant women: CD4 ≤ regardless of level
CD4 < 200 cells/µL, CD4 < 200 cells/ 350 cells/µL, or WHO women: CD4 ≤ 350 350 cells/μL, or WHO of immune
or WHO stage 4 μL, or WHO stage stage 3 or 4 disease cells/μL, or WHO stage 3 or 4 disease suppression
disease 4 disease stage 3 or 4 disease
PMTCT, prevention of mother-to-child transmission of HIV; ART, antiretroviral therapy; AZT, zidovudine; WLHIV, women living with HIV; PWLHIV, pregnant women living with HIV; MTCT, mother-to-
child transmission of HIV; NVP, nevirapine.
†, Infants at high risk of MTCT: mother had no ART or less than 4 weeks of ART during pregnancy and infant breastfed, HIV-positive diagnosis made during breastfeeding.
In 2013, WHO Option B, where all pregnant and postpartum The indicators that we collected data for include the following:
WLHIV were initiated on an efavirenz-based fixed-dose pregnant women presenting for their first antenatal visit and
combination, was introduced. Treatment was stopped gestational age at first visit; pregnant women tested for HIV
23
postpartum if not breastfeeding, or after cessation of during pregnancy and those presenting already known to be
breastfeeding, if the woman was not eligible for lifelong ART living with HIV and whether already on ART; PWLHIV who
for her own health. The most recent PMTCT guideline were issued with single-dose NVP prophylaxis antenatally;
23
change was in 2015 when all pregnant and postpartum PWLHIV who had a CD4 count done during pregnancy and
women living with HIV became eligible for lifelong treatment those who had a CD4 count of < 200 cells/µL and ≤ 350 cells/
regardless of CD4 count level, Option B+. 24 µL; the number of ART-eligible pregnant women who were
initiated on ART; and the number of HIV-exposed infants
The 2013 PMTCT guideline reinforced the recommendation who were tested for HIV and those found to be HIV-positive.
that was first made in the 2010 guideline that pregnant women
who initially tested HIV-negative were to be routinely retested The prevalence of human immunodeficiency virus among
during pregnancy at around 32 weeks’ gestation. For women pregnant women was calculated using the number of
who presented intrapartum with an unknown HIV status, or pregnant women presenting at the first antenatal visit already
with a negative HIV test done prior to 32 weeks’ gestation, known to be living with HIV and those newly diagnosed as
or done more than 12 weeks prior to delivery, the HIV-positive during pregnancy as the numerator and the
recommendation was for retesting intrapartum. Postpartum, total number of first visits as the denominator. The proportion
the recommendation was to repeat the HIV test at 6 weeks of ART-eligible pregnant women was calculated using the
postpartum and every 3 months during breastfeeding. In the number of PWLHIV who had a CD4 count of < 200 cells/µL
2015 guidelines, the recommendation is for routine repeat HIV or ≤ 350 cells/µL, depending on the CD4 count threshold at
testing every 3 months during pregnancy, intrapartum and the time, divided by the total number who had a CD4 count
postpartum as per the 2013 guidelines. Routine testing of HIV- done. For the 2013–2015 data, all PWLHIV who were not on
exposed infants, using HIV polymerase chain reaction (PCR), ART at the first antenatal visit were regarded as eligible for
became standard of care from 2004, and was offered at around treatment, in line with the guidelines. The number of HIV-
6 weeks of age. Also, as part of routine care, an HIV antibody exposed infants who were found to be HIV-positive at around
test was done at 18 months in infants who initially tested 6 weeks of age was used to calculate the MTCT rate, using as
negative at early infant diagnosis. Since 2015, routine testing of the denominator the number of HIV-exposed infants tested
HIV-exposed infants was done at birth, 10 weeks of infant age, in the 13 facilities. Data were analysed using Stata® version
6 weeks post-cessation of breastfeeding and at 18 months. 14.0 (Stata Corporation, College Station, TX, USA).

It is in this background of evolving guidelines and the
changing focus of donor funding that we evaluated the Ethical consideration
Soweto PMTCT programme. The study was approved by the University of the
Witwatersrand Human Research Ethics Committee
Data management and analysis (Reference No. M140461), and access to the facilities was
granted by the Johannesburg Health District Office.
As part of routine reporting to the District Health and
Information System (DHIS), PMTCT data were collected on Results
PWLHIV and HIV-exposed infants, and the indicators
collected changed over time with evolving PMTCT guidelines. From January 2002 to December 2008, around 30 000 pregnant
We extracted aggregate data from paper-based and electronic women presenting for their first antenatal visit were seen in
registers on core PMTCT indicators for the period 2002–2015. the programme annually (Table 2). As services became

http://www.sajhivmed.org.za 341 Open Access