Applying National Guidelines on ART - PMTCT

Authors: Louise Kuhn, PhD
Editor In Chief: Ian M. Sanne, MBBCH, FCP(SA) (More Info)

Last Reviewed: July 8, 2016 (What's New)

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Burden of HIV Infection Among Women and Children in South Africa

The HIV epidemic in South Africa remains the largest in the world, with an estimated 6.8 million South Africans living with HIV in 2014.[UNAIDS 2014] Although the incidence of HIV has been in decline in recent years, HIV infection continues to take a high toll among women and children in South Africa. In 2012, the incidence of HIV among women of childbearing age (age range: 15-49) was recorded at 2.28%.[ZA HIV Prevalence Survey 2012] However, of the 6.8 million South Africans living with HIV in 2014, an estimated 340,000 were children younger than 15 years of age and 3.9 million were females at least 15 years of age.[UNAIDS 2014] The disparity in the HIV prevalence between men and women is particularly pronounced among young adults: In 2014, the HIV prevalence among South Africans 15-24 years of age was 2 times higher in females than in males (8.1% vs 4.0%, respectively).[UNAIDS Info]

Among pregnant women, the HIV epidemic has stabilised during the last few years, but HIV prevalence remains at exceedingly high levels. In 2010, 30.2% of South African women accessing antenatal care were HIV positive.[ZA NDOH Antenatal Survey 2012] It has been suggested that these figures may underestimate the actual prevalence of HIV infection among women of childbearing potential. The high prevalence of HIV among these women manifests in a variety of negative outcomes, including high maternal mortality, an increased risk of orphanhood among children of HIV-positive mothers, and high risks of vertical (mother-to-child) transmission of HIV in the absence of effective preventive measures.[Nannan 2012]

Great strides have been made in the prevention of mother-to-child transmission (PMTCT) of HIV, with coverage of HIV testing of pregnant women now being close to 100%. PMTCT is offered in almost all health facilities in South Africa (98%), the percentage of HIV-positive pregnant women receiving antiretroviral therapy to reduce MTCT has steadily increased from 83.0% in 2009 to 87.1% in 2012, and MTCT has decreased to 2.7% in 2011.[ZA NDOH HIV Tx 2015]

Risks of HIV Infection to Maternal Health

HIV infection is associated with significant health risks to women, including an increased risk of maternal mortality. Although child health in South Africa has improved in recent years, maternal mortality remains high. From 2005-2009, South Africa’s maternal mortality (independent of HIV status) increased dramatically, rising from 150 deaths per 100,000 live births to 190 deaths per 100,000 live births. Between 2009 and 2012, there was a significant decrease in maternal death; indeed, although 176.2 maternal deaths per 100,000 live births were observed in 2008-2010, this number decreased to 146.7 maternal deaths per 100,000 live births between 2011 and 2012.[Moodley 2014] The report identified 5 conditions that contributed to the majority of preventable deaths: nonpregnancy-related infections, including HIV; obstetric haemorrhage; complications of hypertension; medical and surgical disorders; and pregnancy-related sepsis.[Moodley 2014] HIV infection was the most common contributing condition to maternal death. Among HIV-positive women, there were 430.4 maternal deaths per 100,000 live births compared with 75.5 maternal deaths per 100,000 live births in HIV-negative women.

Risks of Maternal HIV Infection to Child Health

Infants born to HIV-infected women are at risk for multiple complications and an elevated mortality, either directly through mother-to-child transmission or indirectly through poor health of the mother.[Nakiyingi 2003; Newell 2004]

Untreated HIV infection in an infant is associated with a poor prognosis. In the early epidemic, fewer than one half of children with vertical HIV infection were expected to reach their fifth birthday.[Newell 2004; Brahmbhatt 2006] This statistic has improved over the antiretroviral therapy (ART) era, however. In a study of all children born between January 2000 and January 2007 in the Africa Centre Demographic Surveillance Area, infant mortality (earlier than 5 years of age) declined by 49.0% from 69.0 deaths per 1000 person-years observed in 2000 to 35.5 in 2006; a significant decline was observed particularly in Years 2004-2006. Mortality in children of mothers receiving ART was not significantly different from children of HIV-negative mothers.[Ndirangu 2012] A 2012 pooled analysis[Becquet 2012] of all prevention of mother-to-child HIV transmission trials indicated that the time of HIV acquisition may affect survival of HIV-infected children. The risk of early death is higher among children acquiring HIV infection perinatally than those acquiring HIV through breast milk, with mortality risks of 60% and 36%, respectively, by 18 months after HIV acquisition.[Becquet 2012] The high rates of mortality highlight the necessity of preventing vertical transmission to improve survival in these children.

Maternal HIV infection contributes to mortality of those younger than 5 years of age in indirect ways as well. Infants born to HIV-infected mothers, particularly those with low CD4+ cell counts, are at greater risk of low birth weight and preterm birth, which are major contributors to neonatal and infant mortality.[Van der Merwe 2011] Moreover, even among infants who do not acquire HIV from their HIV-infected mothers, children whose mothers die are at exceedingly high risk of poor outcomes. Death of a mother is associated with a higher risk of orphanhood, which in itself poses a higher risk of child mortality.[Nakiyingi 2003] There is also some suggestion that maternal HIV infection may have adverse effects on the uninfected child’s developing immune system, but this remains controversial and difficult to prove.[Kuhn 2007]

Finally, maternal HIV has resulted in adverse outcomes for infants through the promotion of formula feeding, which was intended to improve health by preventing HIV transmission but instead increased infant mortality through increased rates of malnutrition and non-HIV illnesses.[Horvath 2009] A recent movement back to promoting exclusive breast-feeding in the context of effective antiretroviral prophylaxis may reverse this trend.