The Impact of Revised PMTCT Guidelines: A View From a Public Sector ARV Clinic in Cape Town, South Africa

BACKGROUND: In April 2010, revised Prevention of Mother-to-Child Transmission guidelines were implemented in South Africa, advising fast-tracked lifelong highly active antiretroviral therapy (HAART) initiation at a higher CD4 count (≤350 cells per microliter). This study describes the impact of these changes on the management of pregnant women who initiated HAART at Tygerberg Hospital, Cape Town. METHODS: We conducted a retrospective review of all women who initiated HAART in pregnancy at the Tygerberg Hospital between January 2008 and December 2010. Year cohorts were compared. RESULTS: Two hundred and fifty HIV-infected women were included in the study and stratified by HAART initiation year: 2008:N = 82, 2009:N = 71, 2010:N = 97. There were no differences between the groups in age or parity. Median booking CD4 count was 155 cells per microliter [interquartile range (IQR) 107–187], 157 cells per microliter (IQR 104–206) and 208 cells per microliter (IQR 138–270), respectively (P < 0.001). Median gestation at HAART initiation was 31 weeks (IQR 27–35), 30 weeks (IQR 26–34), and 25 weeks (IQR 21–31; P < 0.001). HIV transmission rates were 3/65 (4.6%), 4/57 (7.0%), and 0/90 (0.0%; P = 0.021). Women <8 weeks on HAART before delivery were more likely to transmit than women ≥8 weeks [odds ratio 9.69; 95% confidence interval 1.66 to 56.58; P = 0.017]. Ninety-four (37.6%) women were lost to follow-up, 18.4% within 28 days of delivery. CONCLUSIONS: The positive impact of the new Prevention of Mother-to-Child Transmission program is evident. A longer duration of HAART before delivery was associated with less transmission. However, the lost to follow-up rates remain concerning. Further research is needed to better understand the reasons for nonadherence and mechanisms to improve support for these women.