Durban, South Africa | Over the past 15 years South Africa has made incredible, unprecedented progress towards reducing mother to child transmission of HIV (MTCT). National MTCT prevention (PMTCT) strategies have brought the risk of infant HIV infection down from 8% in 2008 to 3.5% in 2010, 2.6% in 2012-13 and an estimated 1.4% in 2015; a far cry from the 20% - 40% infant HIV infection risk measured in the absence of intervention strategies. These results are unprecedented for a national PMTCT programme in a high HIV prevalence setting.
Three national surveys led by the South African Medical Research Council (SAMRC), in partnership with the Centers for Disease Control and Prevention (CDC), University of the Western Cape (UWC), South African National Department of Health, UNICEF and the National Institute of Communicable Diseases, demonstrate sustained reductions in early MTCT nationally and <5% MTCT at 18 months postpartum.
According to these data thus the South African PMTCT programme has saved approximately 80 000-85 000 newborn babies per year, since 2010, from early HIV infection (assuming 1 million live births, 31% infant HIV exposure and 30% MTCT in the absence of PMTCT interventions). Between 2012 and 2014 the SAMRC followed 2644 babies till 18 months of age. In this cohort only 1.6% of babies acquired HIV infection between six weeks and 18 months.
“These findings demonstrate the laudable long-term success of national PMTCT interventions, amongst babies accessing care within the South African health care system,” says the SAMRC principal investigator, Professor Ameena Goga. “One of the main successes since 2010 relates to the policy change to PMTCT Option B which increased maternal access to HIV treatment.
“This low risk of mother-to-child transmission of HIV after 6 weeks was measured in the context of 60% uptake of maternal antiretroviral triple therapy (ART/FDC) and 92% uptake of daily infant nevirapine prophylaxis,” says Professor Debra Jackson, Principal Investigator from UWC.
“This is the first evidence that the roll out of PMTCT interventions is effective and that the elimination of paediatric HIV infection is realisable”, says Professor Glenda Gray, President & CEO of the South African Medical Research Council (SAMRC).
The 2015 revised and consolidated South African PMTCT policy provides all HIV positive pregnant and breastfeeding women with life-long ART. It also recommends that infants are tested for HIV at birth, ten weeks, six weeks after breastfeeding stops and at 18 months.
Dr Thu-Ha Dinh, the CDC principal investigator, says that “Given the 2015 guidelines, South Africa is well poised to further reduce early and long-term mother-to-child transmission of HIV, diagnose infant HIV infection, initiate infant treatment early and improve maternal and child survival and quality of life.” New Department of Health interventions such as MomConnect and B-Wise, which also aim to improve maternal and child health, complement these national PMTCT interventions.
The sustained decline in MTCT is substantiated by routine laboratory and district health information system (DHIS) data and by modelling using the Spectrum model. In 2015, routine laboratory and DHIS data measured 1.8% and 1.5% MTCT, respectively in children less than 2 months of age. Using the Spectrum model in 2015 estimates suggests that early MTCT was 1.4% at 6 weeks postpartum and 2% at 18 months postpartum. This shows that South African is on a successful downward trajectory for reducing MTCT.
FACTUAL NOTES TO THE EDITOR:
% MTCT at 6 weeks after delivery:
- 2010: 3.5% (SA MRC survey 2010)
- 2011-12: 2.7% (SA MRC survey 2011-12)
- 2012-13: 2.6% (SA MRC survey 2012-13)
- 2015: 1.4% (Spectrum 2015 modelling)
Without prevention of MTCT (PMTCT) interventions, 20% -40% of HIV-exposed infants are infected with HIV by eight weeks post-delivery.
% MTCT at 18 months after delivery:
- 2012-14: 4.3% (SA MRC survey 2012-14)
- 2015: 2% (Spectrum 2015 modelling)
Increased access to maternal HIV treatment in numbers:
- 2010: 33%
- 2011-12: 42%
- 2012-13: 55%
- Professor Debra Jackson (UNICEF)
- Dr Thu-Ha Dinh (CDC)
- Professor Ameena Goga (SAMRC)
The SAMRC Evaluations were conducted between June-December 2010, August 2011 and March 2012 and October 2012-May 2013.
- HIV exposed infants enrolled in the 2012 cross-sectional survey were followed up till 18 months postpartum. Amongst the 1.6% of HIV exposed infants who acquired HIV infection between six weeks and 18 months, more than 80% were infected by six months postpartum. This illustrates the need for regular monitoring of HIV exposed infants and early infant HIV testing.
- Amongst HIV exposed infants approximately 60% of their mothers were taking triple antiretroviral therapy. The 18 month data illustrates that continuing HIV treatment amongst postpartum women, or continuing with infant sdNVP throughout breastfeeding reduces transmission of HIV to infants through breast milk in an operational, national setting.
Although only 47% of HIV infected mothers reported visiting the clinic for infant HIV testing, less than 5% of all mothers bringing their children for immunisation refused routine infant HIV testing. This heralds the feasibility and acceptability of early infant diagnosis as a provider initiated service for all infants.
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