Moving towards elimination: findings from the South Africa prevention of mother to child transmission evaluation (SAPMTCTE)

Engagement in antenatal and HIV care among pregnant women before and after Option B+ policy implementation in South Africa

Background

Substantial gains have been made in South Africa in the prevention of vertical transmission of HIV over the past decade.

Objectives

to determine whether engagement in antenatal and HIV care among pregnant Women Living with HIV (WLWH) differed after Option B+ implementation.

Methods

We analysed cohort data from a pregnancy and birth defects surveillance system in KwaZulu-Natal (KZN). We report on two co-primary outcomes related to engagement in HIV care: 1) timing and number of ANC visits during the pregnancy period; and 2) timing of ART initiation (both self-reported ART use in interviews and observed initiation of treatment in maternal records). The association of policy era on the timing of ANC presentation was assessed using log-binomial regression modelling. We also report proportions initiating ART before or during pregnancy stratified by policy era.

Results

Data from 40,357 women, including 16,016 (40%) WLWH were analysed. During the Option B+ era, 24% of pregnant WLWH attended their first antenatal care visit during the first trimester, compared to 16% during the Option B era (RR=1.52;95%CI=1.41-1.64). The proportion of women living with HIV who initiated ART prior to pregnancy was also higher during the Option B+ era compared to the Option B era, though this result was limited by missingness in the data.

Conclusions

Engagement in antenatal and HIV care improved after Option B+ implementation. In the Option B+ era, South Africa has made significant progress towards the goal of eliminating mother-to-child transmission of HIV.

What this study adds

There has been an increase in the proportion of pregnant WLWH initiating ART prior to pregnancy and presenting for antenatal care (ANC) during the first trimester.The findings suggest improved timing and frequency of ANC visits during pregnancy, moving towards the UNAIDS 2025 targets.

Mother-to-Child Transmission of HIV Through Breastfeeding Improving Awareness and Education: A Short Narrative Review

Despite critical progress registered in the reduction of mother to child transmission (MTCT) of HIV worldwide, transmission through breastfeeding still contributes to almost 50% of pediatric HIV infections recorded every year. In this short narrative review, after development of an extensive background on HIV and breastfeeding, some directions are suggested to address the key bottlenecks. Specifically, reinforcing the prevention of MTCT through breastfeeding (BF) in order to move towards elimination of MTCT prior to 2030 may require, among others strategies: tracking all women of child bearing age through HIV testing, improving testing and retesting of women during pregnancy and breastfeeding, strengthening adherence on antiretroviral therapy (ART) among pregnant and lactating women, ensuring continuum and retention in care of mother and baby-pairs up to 24 months, switching ART in non-viral suppressed mothers after improvement of adherence counseling. In addition, due to the burden of seroconversion during pregnancy or thereafter through BF, pre-exposure prophylaxis (PreP) for most at risk women should be implemented urgently. The opportunity to extend the infant prophylaxis to the whole lactating period should be assessed to address residual transmission amongst viral suppressed mothers.

Vaccine strategies to reduce the burden of pneumococcal disease in HIV-infected adults in Africa

INTRODUCTION

Streptococcus pneumoniae is the leading cause of invasive bacterial disease, globally. Despite antiretroviral therapy, adults infected with human immunodeficiency virus (HIV) are also at high risk of pneumococcal carriage and disease. Pneumococcal conjugate vaccines (PCVs) provide effective protection against vaccine serotype (VT) carriage and disease in children, and have been introduced worldwide, including most HIV-affected low- and middle-income countries. Unlike high-income countries, the circulation of VT persists in the PCV era in some low-income countries and results in a continued high burden of pneumococcal disease in HIV-infected adults. Moreover, no routine vaccination that directly protects HIV-infected adults in such settings has been implemented.

AREAS COVERED

Nonsystematic review on the pneumococcal burden in HIV-infected adults and vaccine strategies to reduce this burden.

EXPERT OPINION

We propose and discuss the relative merit of changing the infant PCV program to use (1a) a two prime plus booster dose schedule, (1b) a two prime plus booster dose schedule with an additional booster dose at school entry, to directly vaccinate (2a) HIV-infected adults or vaccinating (2b) HIV-infected pregnant women for direct protection, with added indirect protection to the high-risk neonates. We identify key knowledge gaps for such an evaluation and propose strategies to overcome them.