Neobook — clinical reference

OVERVIEW OF VTP OF HIV

South Africa (SA) is committed to achieving the elimination targets outlined in the Last Mile Plan. Whilst significant progress has been made in preventing HIV infections in children, HIV remains the third leading cause of maternal mortality² , and a significant contributor to under-five deaths in SA. Therefore, managing the health of women living with HIV and preventing vertical transmission of HIV remains a critical intervention for ensuring that women and children survive and thrive in South Africa. PMTCT Option B Plus entailed initiating ART for life in all pregnant and breastfeeding women regardless of CD4 count or clinical stage and was launched in SA in January 2015. As the programme continues to evolve, it is necessary to reflect on new evidence, both scientific and operational, to ensure that SA’s HIV VTP programme remains relevant, practical, and evidence based.

SYPHILIS IN PREGNANCY

Syphilis remains a significant cause of preventable perinatal death in SA.³ According to the 2019 National Antenatal HIV Sentinel Survey, the prevalence of syphilis is estimated at 2.6% (95% CI: 2.4%−2.9%) at national level. Compared to the prevalence of syphilis in 2015 (2.0%), the current syphilis prevalence represents a 30% increase in prevalence between 2015 and 2019. Maternal syphilis screening coverage at first antenatal visit was 96.4% at national level. However, despite good antenatal attendance and early maternal syphilis testing, there has been a resurgence of congenital syphilis (CS) cases in many provinces in South Africa³ . Adverse pregnancy outcomes occur in up to 80% of syphilis seropositive, untreated pregnant women. South Africa has committed to dual elimination of both HIV and syphilis, and greater emphasis is therefore needed on the process of screening and effectively treating mothers, their partners, and their infants affected by syphilis.

TUBERCULOSIS IN PREGNANCY

Non-pregnancy-related infections remain the leading cause of maternal mortality in South Africa. Within this category, respiratory infection remains the most common cause of death, and TB the most common underlying disease. Yet, deaths from TB are likely to be unrecognized, with many deaths due to pulmonary or disseminated TB being attributed to other causes.⁴ Furthermore, maternal TB may result in premature birth, low birth weight, and congenital or neonatal TB infection or disease.⁵ Preventing, diagnosing and treating women for TB must receive greater emphasis if maternal and child outcomes are to be improved in SA.

OTHER INFECTIONS

MALARIA IN PREGNANCY

Pregnant women, particularly in the second and third trimesters of pregnancy, are more likely to develop severe malaria and have a higher malaria-related mortality rate than other adults. Malaria in pregnancy is more frequently associated with complications such as cerebral malaria, hypoglycaemia, anaemia, and pulmonary oedema/adult respiratory distress syndrome. In addition, maternal malaria increases the risk of spontaneous abortion, stillbirth, premature delivery, low birth weight (a leading cause of child mortality) and rarely, congenital malaria. Foetal distress may occur peripartum. The risk of severe malaria extends into the early postpartum period. Pregnant and breastfeeding women living in malaria-endemic areas should therefore be a focal group for malaria prevention interventions. It is important to follow up pregnant women treated for malaria, and their infants, more closely to promptly diagnose and adequately manage any complications of malaria in pregnancy.⁶

HEPATITIS B IN PREGNANCY

Worsening of liver disease in HBV-infected pregnant women is uncommon, but case reports have suggested that HBV reactivation, hepatic exacerbations and fulminant liver failure may occur. Furthermore, maternal HBV infection may result in higher rates of preterm births, lower APGAR scores, gestational diabetes and antepartum hepatitis. Whilst horizontal transmission during childhood remains the primary mode of HBV transmission, vertical transmission remains an important mechanism of infection in countries with high HBV prevalence.⁷ In SA, a large proportion of HBV infected women are also living with HIV and will receive ART during pregnancy. The ART drugs tenofovir and lamivudine treat both HIV and HBV and reduce the risk of vertical transmission by decreasing the viral load of both HIV and Hepatitis B. Health care workers need to be aware of the required management of a HBV-infected mother and her infant as outlined in the National Maternity Care Guidelines.

LISTERIOSIS, ZIKA AND OTHER INFECTIONS

Listeriosis is a disease caused by ingesting food contaminated with the bacterium Listeria monocytogenes. Pregnant women, newborn infants and those with weakened immune systems are particularly at risk and the infection may result in sepsis or meningitis with high mortality. Vertical transmission may result in stillbirth, premature delivery or severe infection in the newborn.¹

Zika virus in transmitted by mosquitos, sexual contact, and contaminated blood products. While the majority of Zika infections are asymptomatic, infected persons may present with a short-lived febrile illness. There is no evidence that pregnant women are more susceptible to Zika virus, or that they are more likely to develop complications of the disease. However, maternal Zika infection may result in congenital brain abnormalities including microcephaly in the infant.⁸

While Zika virus infections may not be an imminent threat in the South African context, the recent outbreak of Listeriosis highlights the importance of universal measures to prevent infections during pregnancy and the breastfeeding period to prevent any form of infection and their consequences during this vulnerable time.

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South African National Department of Health, Guideline for Vertical Transmission Prevention of Communicable Infections, Version 2_August 2023

Overview of Transmittable Infections during Pregnancy and the Breastfeeding Period