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South Africa has one of the highest HIV prevalence rates in the world, with rates in pregnant women averaging 26.5% in the national survey in October 2002.The care of women living with HIV in pregnancy has become an important part of obstetric management.

SASOG endorses the efforts of the Department of Health to implement a comprehensive prevention and care strategy for HIV/AIDS in South Africa. SASOG welcomes the operational plan for comprehensive HIV and AIDS care, management and treatment for South Africa as approved by the Cabinet, and supports the elements of this plan, which include:

• Ensuring that the great majority of South Africans who are currently not infected with HIV remain uninfected.
  
  
• Enhancing efforts in the prophylaxis and treatment of opportunistic infections, improved nutrition and lifestyle choices.
  
  
• Effective management of those HIV-infected individuals who have developed AIDS-defining illnesses, through appropriate treatment of AIDS-related conditions (including the use of antiretroviral therapy in patients with low CD4 counts to improve health and to prolong life), and suitable palliative and terminal care where treatment has run its course.
  

With regard to the care of pregnant women living with HIV and AIDS, SASOG believes that 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 can result in significant reductions in mother to child transmissions. The expansion of the national prevention of mother-to-child transmission of HIV (PMTCT) programme and the use of a simple and inexpensive nevirapine regimen have made these interventions more accessible to South African women, and should continue to be extended to all antenatal services across the country.

As antiretroviral treatment becomes more accessible with the implementation of the national plan, the care of pregnant women living with HIV/AIDS will need to be individualised to provide the most appropriate treatment, as indicated by the clinical condition of the woman.

SASOG supports the principles for antiretroviral treatment in pregnancy outlined in the operational plan, including:

1. The eligibility criteria for pregnant women to start antiretroviral treatment should be similar to those in non-pregnant adults, but consideration should be given to any potential effects on the fetus.
   
   
2. The selection of antiretroviral drugs should take into account the special circumstances of pregnancy. In particular stavudine and didanosine should not be used together in pregnant women, and the use of efavirenz should be avoided in pregnancy, at the current state of knowledge, due to its potential to cause fetal abnormalities. Pharmacovigilance will be essential to monitor for any adverse events associated with the more widespread use of these drugs in women of childbearing potential.
   
   
3. All pregnant women with a CD4 <200 cells/mm3 should be started on antiretrovirals after the first trimester. Pregnant women with CD4 counts between 200 and 350 CD4 cells/mm3 should be strongly considered for initiation of antiretroviral therapy after the first trimester, with therapy to be continued for life.
   
   
4. Women who become pregnant while on antiretroviral therapy should continue therapy without interruption, including during the first trimester.
   
   
5. For those women who do not require antiretroviral therapy for their own health, an appropriate regimen of antiretrovirals should be used to reduce the risk of mother-to- child transmission of HIV. In most circumstances in South Africa, this will be a single dose nevirapine regimen to mother and child, although short course combination antiretroviral therapy may be more effective in reducing the risk of transmission, if available. There should be continued review of the available antiretroviral options for this group of women.
   
   
6. Where the mother is diagnosed during labour, single-dose nevirapine should be provided.
   
   
7. Where the mother has not accessed any antiretroviral treatment before delivery, the child should be treated with single dose nevirapine or another appropriate regimen, such as six-week zidovudine treatment.
   
   
8. Nutritional supplements, pneumocystis pneumonia prophylaxis (with co-trimoxazole) and INH (isoniazide) prophylaxis against tuberculosis should be included in the enhanced care package
   

SASOG believes that the use of single dose nevirapine to mother and baby is a safe, non-toxic and effective intervention, which can significantly reduce the risk of mother-to-child transmission of HIV. There are concerns about the selection of nevirapine-resistant viral variants following this regimen, and further research work is required to elucidate the significance of this selection for the future treatment options for mother and child. This nevirapine regimen should continue to be the baseline PMTCT regimen for those women who do not require, or cannot access, antiretroviral therapy for their own health. As new information becomes available, the use of nevirapine monotherapy should be reviewed and new recommendations made for the prevention of mother-to-child transmission, if indicated.

The offer and provision of appropriate contraception for women living with HIV should be an integral part of their care. Contraceptive choices will have to take into consideration the potential interactions with antiretroviral treatment.

The prevention of new infections in women remains an important goal of South Africa’s HIV AIDS management. Antenatal care and gynaecological services provide an important opportunity counselling and testing, and risk reduction education activities.