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
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:
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.
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
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.
Women who become pregnant while on antiretroviral
therapy should continue therapy without interruption,
including during the first trimester.
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.
Where the mother is diagnosed during labour,
single-dose nevirapine should be provided.
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
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,
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.