Save babies by giving HIV pre-exposure treatment to breastfeeding moms, experts urge
It has proven effective in protecting young women and other high-risk populations from HIV infection, but now scientists want the HIV pre-exposure prophylaxis (PrEP) to be given to pregnant women and breastfeeding mothers due to the persistent HIV infections among this group.
According to leading medical experts and epidemiologists, despite SA’s efforts to prevent mother-to-child transmission that has seen pregnant women initiated on antiretroviral therapy for life irrespective of their CD4 count, the medics contend that it is critical that the country expands its prevention of mother-to-child transmission (PMTCT) programme by giving PrEP to this vulnerable group of women.
In an editorial published in the South African Medical Journal, they argue that if PrEP is not given to this group, including women in serodiscordant relationships, where one partner is infected by HIV and the other is not, this will undermine the government’s efforts to prevent infections to babies.
“It is urgent and overdue to implement PrEP in pregnancy and during breastfeeding. Doing so will align with the national PMTCT policy of strengthening antenatal and postnatal care for both HIV-negative and positive mothers. Failure to do so in the face of proven prevention interventions allows ongoing avoidable HIV infection among women in SA, with the added high risk of transmission to their offspring,” they said.
Dr Dvora Joseph Davey, lead author and honorary senior lecturer at UCT’s school of public health, said high HIV incidence among young women persists during pregnancy and postpartum, and there is evidence that HIV acquisition risk increases by more than two-fold during pregnancy and the postpartum period.
“Acute maternal HIV infection is associated with increased vertical transmission risk, making prevention of HIV among pregnant and breastfeeding women a national health priority,” she said.
According to the 2019 Antenatal HIV Sentinel Study in SA, the prevalence of HIV in first antenatal care visits by pregnant women was 30%. In KwaZulu-Natal the rate was about 41%, while the Western Cape had the lowest prevalence at about 18%.
The same study in 2017, which analysed the data of about 10,000 HIV-negative women, measured new cases of HIV infections to be about 1.5%, based on recent testing. This was against the backdrop of the UNAids target to reduce HIV incidence (new cases) by 75% in 2020, which is the equivalent of reducing new HIV cases by less than 1%.
As a country with highest number of people living with HIV in the world, Davey and her counterparts called on the government to urgently take the following steps:
- implement PrEP prescription for pregnant and breastfeeding women;
- allow nurse-initiation and management of ART-trained nurses and midwives to prescribe PrEP in antenatal clinics and postnatal settings;
- include PrEP as part of the updated PMTCT guidelines for HIV-uninfected women at substantial risk; and
- simplify PrEP guidelines to ensure that it is provided on the same day as antenatal care to at-risk women, along with counselling on how best to ensure adherence to the daily pill.
Co-author and director of the Desmond Tutu HIV Centre at UCT, Prof Linda-Gail Bekker, said there are about 1-million live births in SA annually, of which about 70% occur in women not living with HIV.
“Many of these women are at very high risk of HIV acquisition and subsequent vertical transmission,” she said.
“These women have the right to access PrEP to protect them against HIV during this high-risk period. Currently in SA, around one in three infant infections arise from maternal seroconversion during pregnancy or breastfeeding. SA will continue to struggle to reach the elimination goals unless the government ensures that women at risk can access an effective biomedical prevention option during their pregnancy and breastfeeding journey.”
Bekker said demonstration studies from her and Davey’s team in SA reported high acceptability and feasibility of integrating PrEP into antenatal and postnatal care.
“A recent study in Cape Town demonstrated that more than 85% of HIV-uninfected women accepted PrEP at their first antenatal clinic visit, and more than 70% continued on PrEP at month one, and 60% at month three. Those who were at higher risk, who were diagnosed with a sexually transmitted infection, had a partner living with HIV or had more than one sex partner, were more likely to continue on PrEP.”
Bekker noted that antenatal care uptake in SA is high, reaching more than 95%, creating a perfect opportunity to offer PrEP to women engaging in these routine services, including priority groups such as adolescent girls and young women and serodiscordant couples.
“Expanding PrEP implementation to include pregnant and breastfeeding women will further support SA’s efforts to reach its ambitious PrEP uptake goals.”
Other authors of the editorial include:
- Dr Natasha Davies, HIV clinician from Anova Health Institute in Johannesburg;
- Yvette Raphael, co-founder and co-director of Advocacy for Prevention of HIV and Aids (Apha); and
- Dr Yogan Pillay, the former deputy director-general for health programmes who joined the Centre for Global Health Innovation (Chai) last year.