Maternity clinics in South
Africa have the potential to achieve zero transmission of HIV from mother to
child, according to a review at Tygerberg Infectious Diseases Clinic comparing infant and
maternal outcomes before and after the April 2010 recommendation of lifelong
antiretroviral therapy for all mothers with CD4 cell counts below 350 cells/mm3.
The study found that in 2010
no HIV transmissions occurred to 90 infants born to mothers diagnosed with HIV,
compared to transmission rates of 4.6% and 7% in 2008 and 2009 respectively.
This finding is comparable to transmission rates observed in resource-rich
settings, investigators from Stellenbosch University report in the advance
online edition of the Journal of Acquired
Immune Deficiency Syndromes.
The study also found that, throughout the study period, being
on antiretroviral therapy (ART) for a longer time and at a higher CD4 count before delivery was linked
to a decreased risk of HIV transmission. The investigators recommend that women
should be encouraged to book their first visit to the maternity clinic as soon
as possible after learning they are pregnant, so that HIV testing and linkage
to care can take place as early as possible in pregnancy.
Women on ART for less than
eight weeks before delivery had a close to tenfold increased risk of
transmitting HIV compared to women on ART for eight weeks or more; odds ratio
(OR) 9.69; 95% CI: 1.66-56.58, p = 0.017.
The percentage of those on
ART for more than eight weeks increased significantly from close to half (47.8%)
in 2009 to nearly three-quarters (73.7%) in 2010 following implementation of
the new guidelines.
However, loss to follow-up
(LTFU) remained unacceptably high. Overall, close to 40% (94) were lost to
follow-up within one year of starting ART, of which almost half were lost within
the first eight weeks of starting ART. LTFU according to year of starting ART
was 31.7%, 54.9% and 35.1% for 2008, 2009 and 2010, respectively.
South Africa, with an
estimated 5.6 million people living with HIV, continues to have the world’s highest
HIV burden. In 2010, HIV prevalence among pregnant women attending antenatal care (ANC) in Cape
Town Metro area was 20.2%, comparable to that of women delivering at Tygerberg
Since 2003, implementation of PMTCT (prevention of mother-to-child transmission)
interventions in all public sector antenatal service facilities in the Western
Cape ensure all pregnant women with low CD4 counts are eligible for lifelong
ART. In 2008, Western Cape PMTCT guidelines recommended ART for women with CD4
counts under 250 cells/mm3 or WHO Stage 4 HIV disease.
In April 2010, revised PMTCT
guidelines recommended fast-tracking the start of ART within two weeks of
diagnosis for all women with CD4 counts equal to or less than 350 cells/mm3
or WHO stage 3 or 4 HIV disease.
Starting ART early in
pregnancy has resulted in MTCT rates of 0 to 2.9% in resource-rich settings.
While the national PMTCT
evaluation survey reported an overall MTCT rate of 3.9% (1.9-5.8) in 2010 in the
Western Cape Area, there have been limited data on the performance of ART
services in South Africa’s public sector. A recent study from a community-based
clinic in Cape Town found a rate of 5.1% in women starting ART before delivery.
The authors evaluated the
effect of the 2010 guidelines on the management of pregnant women starting ART
at Tygerberg ID clinic by looking at the yearly MTCT outcomes over a three-year
The Tygerberg ID clinic,
within the Tygerberg Academic Hospital, provides tertiary level infectious
disease specialist care to half of the Western Cape Province and primary level
ART care to those living in the Tygerberg sub-district. Pregnant women needing
ART are referred from the Tygerberg High Risk ANC clinic and several
community-based ANC clinics without ART facilities in the sub-district.
Among the 250 women 82, 71
and 97 started ART in 2008, 2009 and 2010, respectively. Baseline
characteristics were similar with no statistical differences in age, parity or
gestation at delivery among the cohorts.
There was a significant
difference in median CD4 count at the first ANC visit (booking) in 2010
compared to 2009: 208 cells/mm3 (Interquartile range IQR:138-270)
and 157 cells/mm3 (IQR: 104-206), p<0.001, respectively.
Median gestation at the start
of ART decreased significantly in 2010 compared to 2009, 25 weeks (IQR: 21-31)
and 30 weeks (IQR: 26-34), p<0.001), respectively with a corresponding significant
increase in the time on ART before delivery.
Overall only 63% of women
booked before 24 weeks gestation. While booking did improve significantly in
2010 (median of 17 weeks) 9.2% booked at 30 weeks gestation or later, so
limiting the window of opportunity for ART to be effective before delivery.
Fast-tracking the start of
ART made no difference in reducing MTCT. A median time of five weeks between booking
and starting ART was consistent over the three-year period. In 2010, only 4% of
women started ART within the specified two weeks after diagnosis.
The median time between the
first visit at Tygerberg and starting ART differed significantly in 2010
compared to 2009, 1.1 weeks (IQR: 1.0-2.0) and 2 weeks (IQR: 0.8-3.8), p-0.030.
Most treatment delays happened during referral to Tygerberg so identifying the
bottleneck and poor integration of services is highlighted by the researchers.
“Expansion of ART sites in
the community with fast-track appointments for pregnant women is recommended. Integration
of services with ANC health workers starting and monitoring ART is proposed, as
this would eliminate the referral process entirely.”
The longer a woman was on ART
before delivery, the lower the risk of LTFU. Conversely, women starting ART at
36 weeks gestation or later, were more likely to be LTFU within
a month. More than one in five (18.4%) of all LTFUs happened within 28 days of
“The magnitude of reported
LTFU remains of great concern... Emphasis on retention in care should be
promoted by developing efficient referral feedback systems between community
ANC clinics and baby clinics and strengthening patient tracing capacity.”
The authors conclude “the
positive impact of the new PMTCT programme is evident…with earlier access…the
focus should shift toward educating women of the benefits of early booking to
effect immediate referral to ART facilities after HIV diagnosis and ensuring
women remain in care in the post-natal period.”