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South Africa is in the grip of one of the worst epidemics ever and the impact on society, health care resources and the economy of the country will be enormous although currently impossible to estimate.

SASOG believes that AIDS is the result of infection with the human immunodeficiency virus (HIV) and that many of the complications are exacerbated and aggravated by poverty, suboptimal nutrition and an unhealthy environment. In South Africa the disease is spread predominantly by heterosexual intercourse. Homosexuality and use of contaminated needles account for a very small proportion of cases.

While at this stage generalised medical treatment of HIV infected persons is logistically and economically impossible in South Africa, SASOG endorses the efforts of government and NGOs to raise the level of awareness of HIV/AIDS in all sectors of the population. This includes:

1. bringing appropriate information to target groups and in particular our young people
   
   
2. encouragement of safe sexual practices (emphasizing monogamy) and liberal availability of condoms
   
   
3. voluntary HIV counselling and testing, integrated into existing antenatal structures
   
   
4. implementation of protocols to reduce mother to child transmission
   
   
5. aggressive and early management of all AIDS related diseases
   
   
6. the importance of continuing research into HIV for African solutions
   
   

Substantial progress has been made in the management of women with HIV/AIDS over the last decade. As regards the speciality of Obstetrics and Gynaecology, the provision of a package of prenatal HIV counselling and testing into existing antenatal care structures, availability of effective antiretroviral prophylaxis, appropriate measures taken during labour and delivery, and access to infant formula feeds have resulted in such significant reductions in mother to child transmissions that new perinatal transmissions are uncommon. These benefits however have predominantly been witnessed in affluent societies. Moreover, poor countries including South Africa are faced with an increasing number of maternal deaths due to HIV/AIDS related puerperal sepsis and an increasing population of AIDS orphans.

SASOG is convinced that the key to the prevention of HIV infections in Obstetrics and Gynaecology is primary prevention of infection in women. The importance of wider public education to promote monogamous relationships and other safe sexual practices is of critical importance. Accessibility to appropriate prophylactic antiretroviral interventions, the use of simple inexpensive and non-antiretroviral interventions in labour, and the possibility of offering choices regarding breast feeding and access to formula feeding must be promoted. In addition, enhanced care during pregnancy and the puerperium is relatively inexpensive and also easy to implement: nutritional supplements, pneumocystis pneumonia prophylaxis (with Bactrim), and INH (isoniazide) prophylaxis against tuberculosis should be considered in the enhanced care package.

Most HIV infected women are young and reproductively active. While much attention has been given to HIV positivity in pregnancy, little has been done regarding future pregnancies and contraception. This is of particular importance as women who choose not to breastfeed may lose the effect of lactational amenorrhoea and many do not use oral contraception appropriately.

Prepared by Prof Jack Moodley and Dr Peter Macdonald.
Edited by Prof Gerhard Lindeque.
August 2001