Mon. Jan 17th, 2022

A global goal of eliminating mother-to-child transmission of HIV globally was set in 2015. The ambitious goal of the United Nations (UNAIDS) program was to reduce new infant HIV infections by 75% by 2020. This equates to reducing new infections to less than 1%.

South Africa has the largest number of people living with HIV in the world: over 7.7 million. The country also has the largest HIV epidemic among pregnant women. Over a third of pregnant women have HIV, which contributes to one of the highest rates of vertical transmission (HIV from mother to infant), estimated at 3.9% by 2020.

South Africa has been committed to achieving the elimination of mother-to-child transmission of HIV since 2015. It introduced policies that provide lifelong antiretroviral therapy to all pregnant women living with HIV. But over six years later, new infections in high-speed pregnant women continue.

Since 2017, the World Health Organization (WHO) and several national HIV programs have recommended offering daily oral preventive medicine technically known as pre-exposure prophylaxis (PrEP) to pregnant and breastfeeding women at risk of contracting HIV. PrEP is the use of antiretroviral therapy to prevent the acquisition of HIV in people not living with HIV. The recommendation is based on a large amount of safety data from women living with HIV who used the same drugs as treatment during pregnancy and lactation.

Not offering preventive treatment to women not living with HIV but at risk of acquiring HIV undermines the effectiveness of all South African efforts to eliminate mother-to-child transmission of HIV. Implementing PrEP during pregnancy and lactation is urgent and too late. Failure to do so in the light of documented preventive interventions allows for a persistently avoidable HIV infection among women in South Africa with the increased high risk of transmission to their infants.

In the absence of PrEP, we estimate that over 90,000 infants will acquire HIV in the next 10 years. Our team’s mathematical models estimate that by providing PrEP to pregnant and lactating women in South Africa, we can reduce the incidence of HIV in mothers and infants by up to 136,000 in the optimistic scenario. This is equivalent to estimates of PrEP supply among female sex workers and men having sex with men.

Prevention of new infections

There are approximately 1 million live births in South Africa annually. About 70% – equivalent to 700,000 live births – involve women not living with HIV. Many of these women are at very high risk of HIV acquisition and infant HIV transmission due to a combination of biological and behavioral factors. These include partners living with HIV, multiple partners and frequent condom-free sex.

These women have the right to access PrEP to protect themselves from HIV during this high-risk period. Currently, about one in three infant infections in South Africa occurs from mothers who get HIV during pregnancy or breastfeeding.

South Africa will continue to fight to achieve the elimination goals unless the government ensures that women at risk of HIV exposure can access effective biomedical prevention options during their pregnancy and breastfeeding.

Expected reductions in HIV incidence due to PrEP, 2020-2030, under various improved PrEP delivery scenarios.
Author indicated

Ongoing studies show a high susceptibility to PrEP among South Africans. This suggests that PrEP can be integrated into prenatal and postnatal care. A recent study we did in Cape Town showed that over 85% of women without HIV accepted PrEP at the first pregnancy visit, and over 70% continued with PrEP in the first month and 60% in the third month.

Those at higher risk for HIV acquisition were more likely to continue and adhere to daily PrEP. The higher risk identifiers are a sexually transmitted infection, a partner living with HIV or having more than one sexual partner. The Cape Town study also showed the safety of giving PrEP to this population, in line with other studies in the region.

The incidence of antenatal care in South Africa is high and reaches over 95%. This provides a perfect opportunity to offer PrEP to women seeking routine services. Extending PrEP implementation to pregnant and breastfeeding women will further support South Africa’s efforts to achieve its ambitious goal of eliminating infant HIV.

Expansion of existing programs

Oral PrEP is scaling up among pregnant and breastfeeding women in sub-Saharan Africa with notable implementation successes in Kenya and ongoing demonstration projects in South Africa, Lesotho, Malawi, Zambia and Zimbabwe.

The South African government should support the immediate training of healthcare providers and the integration of PrEP into maternity and postpartum care for all women at risk of HIV. All pregnant women who test HIV-negative at their first pregnancy visit should receive the offer to start PrEP. This should be accompanied by comprehensive HIV prevention services, including counseling to support them to take daily PrEP while pregnant and breastfeeding.

Maternal HIV programs, which include primary prevention of HIV through the use of PrEP in pregnant and breastfeeding women at high risk for HIV, are the key to achieving the goal of eliminating HIV in infants.

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