Skip to main content
NCBI home page
Obstetric Medicine logoLink to Obstetric Medicine
. 2025 Feb 20;18(4):249–255. doi: 10.1177/1753495X251317263

Adherence to HIV vertical transmission prevention (VTP) policies in a tertiary-level obstetric unit in South Africa

Jarrod Zamparini 1,2,✉, Sulaiman Hassan 2,3, Natasha Davies 4, Wilhelm Herbst 2,3, Shastra Bhoora 5,6,7, Robert Nyakoe 6,7, Lawrence Chauke 6,7
PMCID: PMC11840821  PMID: 39991630

Abstract

Background

HIV disproportionately affects women of childbearing age in South Africa. Despite progress in antiretroviral therapy access, challenges persist in HIV vertical transmission prevention (VTP).

Methods

We conducted a single-centre, retrospective observational audit of women delivering between May and August 2023 at the Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa to assess adherence to national VTP guidelines.

Results

Of 563 women, 22% (125/563) were living with HIV at their first antenatal visit, increasing to 24.3% (137/563) by delivery. HIV retesting rates declined from 46% (181/394) at the second visit to 20% (30/151) by the eighth. HIV viral load testing was performed in 71.5% of women (98/137) at delivery, with 72.4% (71/98) achieving viral suppression. Birth PCR testing was not performed for 21.1% (29/137) of HIV-exposed infants.

Conclusion

Significant gaps in HIV retesting, viral load monitoring, and birth PCR testing highlight ongoing challenges in VTP guideline adherence.

Keywords: HIV, vertical transmission prevention, antenatal care, public health, pregnancy

Introduction

As of 2022, there were approximately 7.8 million people living with HIV (PLWH) in South Africa, with an overall prevalence of 12.7%. 1 The prevalence is higher (24.1%) among women aged 19–45 and among women attending antenatal clinics (27.5%), illustrating that HIV disproportionately affects women of childbearing age.2,3 This is concerning as HIV infection during pregnancy and in the preconception period are major drivers of perinatal transmission. 4 This reiterates the need for early detection of HIV during pregnancy with immediate initiation of antiretroviral therapy (ART) and comprehensive monitoring and management to ensure viral suppression.

Despite the overall decline in the maternal mortality rate (MMR) in South Africa, from 188.9 to 98.82 per 100,000 between 2009 and 2019, HIV remains a major contributor to maternal deaths. 5 In the 2017–2019 triennium, 88.2% and 57.8% of maternal deaths due to non-pregnancy-related infections (NPRI) and pregnancy-related sepsis (PRS), respectively, occurred in women living with HIV (WLWH). 4 Concerningly this is largely unchanged from the 2008–2010 triennium where 87% and 60% of maternal deaths due to NPRI and PRS, respectively, occurred in WLWH. 6 This reflects the findings of a large multicentre study that showed that WLWH had an MMR 5.2 times greater than women without HIV. 7

Progress has been made; between the 2008–2010 and 2017–2019 triennia, the HIV positivity rate amongst women who died during pregnancy and the puerperium declined from 56.6% to 46.8%, likely reflecting the expanded access to effective ART and a reduction in AIDS-related deaths. It is striking that, while just under 30% of pregnant women are living with HIV, 47% of maternal deaths occurred in WLWH. Although the vertical transmission prevention (VTP) programme appears to be identifying more WLWH, as reflected by a decline in maternal deaths occurring in women who had declined HIV testing or in those with an unknown HIV status (19.8% vs. 11.1%), significant gaps still remain in the provision of quality services throughout pregnancy and breastfeeding for those WLWH.5,6

These improvements likely reflect steps taken by the National Department of Health (NDOH) to reduce the burden of HIV infection, specifically through the adoption of a test-and-treat strategy as well as the aim to achieve the WHO 95-95-95 targets (95% of people know their HIV status, 95% of those living with HIV are on treatment and 95% of those on treatment are virally suppressed by 2030).8,9 Whilst the most recent (2022) antenatal care (ANC) survey has shown that 96% of women know their status and 98.8% of WLWH are on treatment, only 74.1% of women are virally suppressed. 2

A further concern is the lack of continued ART adherence during and following pregnancy; a meta-analysis of 51 studies showed that only 73.5% of women maintained adequate adherence throughout pregnancy. 10 Similarly, in a South African study, the probability of women continuing ART to 18 months postpartum was only 63.4%. 11 Only 73.1% of WLWH who died during the 2017–2019 triennium were on ART.

Most HIV infections in paediatric populations arise from vertical transmission (VT), either occurring in utero, at the time of delivery or, during breastfeeding. In the absence of ART, most transmissions occur at the time of delivery (15–20% transmission rate) or during breastfeeding, while intrauterine transmission is the least common route of transmission (5–10%). 12 It is widely accepted that maternal viral suppression at the time of delivery is associated with a perinatal transmission risk close to, if not, zero, making effective, suppressive ART during pregnancy the key goal to eliminate perinatal transmission.13–15 Achieving ART coverage of 95% and greater in pregnancy will likely result in the elimination of VT; and maintaining viral suppression during pregnancy, delivery and breastfeeding reduces the risk of VT to less than 1%.8,16

VT rates have fallen drastically since the advent of the VTP (formerly PMTCT, prevention of mother-to-child transmission) programme – the national VT rate fell from 29.93% in 2000 to 2.76% in 2021. 17 However, despite the availability of ART to all PLWH in South Africa, there were still approximately 10,000 new HIV infections and 980 HIV-associated deaths in children under 4 years of age in 2021. 17

The integration of HIV care into routine ANC through an ‘expanded package of care for the mother–infant pair and their family’ 18 allows pregnant women to receive HIV care from their ANC provider, including midwives, general practitioners and obstetricians. The South African Guideline for Vertical Transmission Prevention of Communicable Infections, 19 has clear recommendations in place for the management of HIV in pregnancy which we have summarised in Table 1.

Table 1.

Summary of the South African guideline for vertical transmission prevention.

Aspect Description
HIV testing Performed at the first antenatal visit for all women who are HIV-negative or unaware of their status.
HIV testing is repeated at all subsequent antenatal visits and at delivery
Women who test positive for the first time in pregnancy ART is initiated at diagnosis, irrespective of CD4 count, clinical stage or gestational age
CD4 count testing at diagnosis and again 3 months after diagnosis
HIVVL 3 months after starting ART and at delivery for newly diagnosed women
Women who are not virally suppressed by 3 months are retested 4–6 weeks after reassessment and intervention
Pregnant women living with HIV at the first antenatal visit Current ART regimen, at the first antenatal visit, should be continued
CD4 count testing as per the national guidelines: 3 and 12 months after ART initiation and every 6 months for known WLWH with CD4 <200 cells/mm3
HIVVL testing at the first antenatal (booking) visit and again at delivery if the booking viral load is undetectable
Women who are not virally suppressed at the first antenatal visit are retested 4–6 weeks after reassessment and intervention
Infant testing Birth PCR for all HIV-exposed infants, with prophylaxis based on maternal delivery viral load and feeding decisions
Opportunistic infection prevention PJP prophylaxis (co-trimoxazole) for all WLWH with CD4 <200 cells/mm3
TPT (Isoniazid) for all WLWH without active TB and not currently on TPT or have never had TPT previouslya
Open in a new tab

ART: antiretroviral therapy; HIVVL: HIV viral load; WLWH: women living with HIV; PJP: Pneumocystis jirovecii pneumonia; TPT: tuberculosis prevention therapy; TB: tuberculosis.

a

In our centre, we initiate TPT when the CD4 count is less than 350 cells/mm3.

We aimed to evaluate adherence to National HIV VTP guidelines in a central Obstetric referral centre in Johannesburg, South Africa. Routine VTP services in our centre are provided by staff from the Department of Obstetrics, including midwives and specialist obstetricians. In the case of complicated HIV infections (e.g., women on third-line antiretrovirals or those with an unsuppressed HIV viral load [HIVVL]) additional care is provided by an HIV specialist, Infectious Disease specialists and an Obstetric Physician from the Division of Infectious Diseases and the Obstetric Internal Medicine Unit.

Methods

Study design

We conducted a single-centre, retrospective observational audit of the files of women who delivered in the Department of Obstetrics and Gynaecology at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) between 1 May and 31 August 2023, both dates inclusive. The Department of Obstetrics and Gynaecology at CMJAH serves women with high-risk pregnancies from urban Johannesburg and surrounds. Approximately 9500 deliveries are performed per year (790 per month) and, based on the provincial HIV prevalence of 26.4%, 2 we expected that approximately 209 deliveries per month occurred in WLWH. Using Cochran's Formula, we calculated the sample size using the total number of deliveries over a 4-month period, including both WLWH and women living without HIV. We used this method to ensure a representative sample of all deliveries, allowing us to draw conclusions relevant to the total population. We aimed to audit 343 files to achieve a 95% confidence level with a 5% of margin error. Women who did not deliver during their admission and those who did not deliver at CMJAH were excluded from the study.

Data collection

The clinical maternity records for the time period concerned were accessed from the records department and demographic, pregnancy, booking (first antenatal visit) and HIV data were captured directly in Google Forms (Google LLC, Mountain View, CA, USA) and exported to Microsoft Excel 16.79 (Microsoft Corporation, Redmond, Washington) for analysis. No patient-identifying information was collected. While we did audit retesting in women living without HIV, we did not audit any measures of prevention in these women (i.e., preexposure prophylaxis, condom use, education, etc.)

Data analysis

Data were analysed using Microsoft Excel 16.79 (Microsoft Corporation, Redmond, Washington) and Prism 9.4 (GraphPad Software Inc., La Jolla, CA, USA). Normality was assessed using the Shapiro–Wilk normality test and data found to be non-normally distributed, thus non-parametric tests were used for analysis. Categorical variables, including the number of women who were living with HIV, the number with a viral load or CD4 done and the number of women who received tuberculosis preventative therapy (TPT) and/or Pneumocystis jirovecii pneumonia (PJP) prophylaxis, are expressed as percentages and frequencies. Comparative analysis of the categorical variables was performed using the chi-square test. Continuous variables such as age, CD4 and HIVVL are presented as medians with interquartile ranges. We did not perform comparative analysis of the continuous variables.

Results

Demographics

During the period under review, 2024 women delivered at CMJAH, and 589 files were audited. Several files were unavailable, as they were being reviewed as part of other ongoing audits, and 26 files were duplicate records and were excluded from the final analysis resulting in a final cohort of 563 women. The median age of women in the cohort was 29 years (interquartile range [IQR]: 25–34) with a median gravidity of three pregnancies (IQR: 2–4). Median gestational age at the first antenatal visit was 22 weeks and 3 days (IQR: 15.5 + 1–27 + 5) and 38 weeks and 1 day (IQR: 37 + 0–40 + 3) at delivery.

First antenatal visit and HIV status

Five hundred and twenty-five women (525/563, 93%) had attended ANC prior to delivery with 7% (38/563) presenting for the first time in labour. Four hundred (400/563) women (71%) were HIV-negative at their first antenatal visit, whilst 22% (125/563) were living with HIV at the first antenatal visit. By delivery 24.3% (137/563) of women were living with HIV; 11 women were first noted to be living with HIV at the time of delivery, as they had not received ANC throughout pregnancy, and 1 was diagnosed with HIV at her eighth antenatal visit. For those with a prior negative HIV result, 102 women were not retested for HIV at delivery (102/563, 18%). There was a statistically significant decline from the first antenatal visit to delivery in the number of women who were HIV negative (400/563, 71% vs. 324/563, 57.5%, p < 0.001), although this is largely attributed to the number of women who were not retested at delivery (102/563, 18.1%). This is shown in Table 2.

Table 2.

HIV data at booking and delivery.

Booking Delivery Significance
HIV status
 Living with HIV, n (%) 125 (22.2%) 137 (24.3%) p < 0.001
 HIV negative, n (%) 400 (71%) 324 (57.5%)
 Unknowna, n (%) 38 (6.7%) 102 (18.1%)
HIV viral load
 Done, n (%) 84 (67.2%) 98 (71.5%) p = 0.311
 Not done, n (%) 25 (20%) 39 (28.5%)
 Not applicable, n (%) 16 (12.8%)
 <50 copies/ml, n (%) 62 (73.8%) 71 (72.4%) p = 0.979
 50–1000 copies/ml, n (%) 13 (15.5%) 16 (16.3%)
 >1000 copies/ml, n (%) 9 (10.7%) 11 (11.2%)
CD4
 Done, n (%) 112 (81.7%) Done at any time during the pregnancy
 Not done, n (%) 25 (18.3%)
 <200 cells/mm3, n (%) 15 (13.4%)
 200–350 cells/mm3, n (%) 19 (17%)
 351–500 cells/mm3, n (%) 30 (26.8%)
 >500 cells/mm3, n (%) 48 (42.9%)
Prophylaxis
 None, n (%) 29/34 (85.3%)
 Co-trimoxazole, n (%) 4/15 (26.7%)
 TPT, n (%) 4/34 (11.7%)
Open in a new tab

TPT: tuberculosis preventative therapy.

a

The unknown group are those that are unbooked (if in the ‘Booking’ column), or unclear if they were tested (if in the ‘Delivery’ column).

HIV retesting in women living without HIV

There was a statistically significant (p < 0.001) decline in the percentage of women being re-tested for HIV at each subsequent antenatal visit. By the second antenatal visit, 45.9% (181/394) of previously uninfected women had been retested, and by the fifth visit, this had remained relatively unchanged at 46.3% (139/300). However, by the eighth visit, only 19.9% of women (30/151) were retested with a further decline to 10% (11/110) at the tenth antenatal visit. The national policy recommends eight standard ANC visits, but some women in our cohort had more than this due to the high-risk nature of care delivered at our centre. Additionally, documentation gaps were observed, with 8.9% (35/394) lacking a recorded HIV test result in the file at the second visit, increasing to 59.1% (65/110) by the tenth visit. This data is shown in Table 3 and Figure 1.

Table 3.

Number of women tested for HIV at each antenatal visit.

Not retested, n (%) Retested, n (%) Unknown if retested, n (%) Significance
Second visit (n = 394) 178 (45.2%) 181 (45.9%) 35 (8.9%) p < 0.001
Third visit (n = 369) 154 (41.7%) 177 (48%) 38 (10.3%)
Fourth visit (n = 347) 137 (39.5%) 160 (46.1%) 50 (14.4%)
Fifth visit (n = 300) 113 (37.7%) 139 (46.3%) 48 (16%)
Sixth visit (n = 250) 105 (42%) 90 (36%) 55 (22%)
Seventh visit (n = 197) 74 (37.6%) 64 (32.5%) 59 (29.9%)
Eighth visit (n = 151) 60 (39.7%) 30 (19.9%) 61 (40.4%)
Ninth visit (n = 119) 36 (30.3%) 19 (16%) 64 (53.8%)
Tenth visit (n = 110) 34 (30.9%) 11 (10%) 65 (59.1%)
Open in a new tab

The number of women eligible for testing declined with each visit as women delivered and did not require further antenatal follow-up.

Figure 1.

Figure 1.

Open in a new tab

Percentage of women who were tested for HIV at each antenatal visit.

Viral load monitoring and suppression

In the 125 WLWH at the time of their first antenatal visit, 12.8% of women (16/125) were newly diagnosed and did not receive a baseline HIVVL as per current guidelines. Of the 109 women with a pre-existing HIV diagnosis, 77.1% (84/109) had an HIVVL measured at the first antenatal visit and 22.9% (25/109) did not, missing this crucial monitoring step. We were unable to assess which ART regimen the women in our cohort were on as this was not clearly documented in the antenatal records. At the time of delivery, 98/137 women (71.5%) had their HIVVL measured and 39/137 (28.5%) did not. In women with a measured viral load, 62/94 (73.8%), were virally suppressed (HIVVL less than 50 copies/ml) at their first antenatal visit. Nine women (9/94, 10.7%) had an HIVVL >1000 copies/ml. At delivery, 72.4% of women (71/98) were virally suppressed, while 11.2% (11/98) had an HIVVL >1000 copies/ml. There was no statistically significant change in viral suppression rates between the first antenatal visit and delivery (p = 0.868). The lowest detectable viral load in our cohort was 42 copies/ml and the highest 3,360,000 copies/ml.

No neonates were confirmed to have acquired HIV in-utero, based on available birth HIV PCR results, however, 21.1% of infants (29/137) did not have a birth PCR performed at the time of delivery and so their HIV status could not be confirmed.

CD4 count monitoring and prophylaxis

One hundred and twelve (112/137, 81.7%) women had a CD4 count done at some point during the pregnancy. There were 34 women (34/112, 30.4%) who had a CD4 count of less than 350 cells/mm3, 31 of whom were known to be living with HIV at the first antenatal visit, and 3 who had not received ANC during their pregnancies. Of the 34 women with a CD4 count of less than 350 cells/mm3 who were, according to guidelines at the time, eligible for TB preventive therapy (TPT), only 12% (4/34) received TPT. Only 4 of the 15 women (23%) who were eligible for PJP prophylaxis, with a CD4 count of less than 200 cells/mm3, received this therapy, as noted in Table 2.

Discussion

Our study provides valuable insights into the current state of adherence to the South African VTP Guidelines. Key findings include a 24.3% (137/563) prevalence of HIV among pregnant women at the time of delivery, a decline in HIV retesting during antenatal visits, suboptimal viral load monitoring, and a 21.1% gap in birth HIV-PCR testing. In addition, gaps were identified in CD4 count monitoring and the provision of prophylaxis, reflecting missed opportunities for optimising maternal HIV care and reducing VT risk. These findings underscore the need for improved HIV care within antenatal services in our centre. Given the challenges in adherence observed in an academic centre, it raises concerns about how well these guidelines are being implemented in community clinics and other primary care settings, where resources and staffing may be more limited.

While the 24.3% prevalence of HIV in our cohort aligns with the national prevalence for women of childbearing age (24.1%), it is lower than the national antenatal prevalence of 27.5%.2,3 As the HIV status of 102 women (102/563, 18.1%) was unknown at delivery, the true number of WLWH in our cohort is likely to be as high as 28.5%. This is based on a crude assumption that, in keeping with the national prevalence, 24.1% of the 102 women with an unknown HIV status may have been living with HIV at delivery, resulting in an additional 24 WLWH. This would bring the total estimated number of WLWH at delivery to 161, increasing the overall prevalence to 28.5% (161/563). Furthermore, the ‘true’ rate of women who did not know their HIV status at delivery should be reflected as 23.9% (102/426), as opposed to 102/563 (18.1%), as WLWH would not require retesting at delivery. This is in keeping with findings from a study conducted in Cape Town, South Africa, where only 23% of women eligible for HIV testing at delivery were retested. 20 This is concerning as close to a quarter of women appear to exit ANC unaware of their HIV status.

The significant decline in HIV retesting during antenatal visits – from 93.3% (525/563) at the first antenatal visit to 19.9% (30/151) by the eighth antenatal visit – mirrors findings from other South African studies conducted in Cape Town and the North West Province of South Africa.20,21 This could reflect several factors, including testing fatigue (in both patients and staff), perception that a single negative test suffices, staffing constraints (due to inadequate staff-to-patient ratios), availability of test kits, and socioeconomic factors. 22 These barriers are exacerbated by late booking for ANC, which was seen in our cohort, with a median gestational age of 22 + 3 weeks at the first antenatal visit. Late booking has been previously associated with reduced HIV testing, as seen in studies conducted in both South Africa and Tanzania.20,23 Additionally, a study conducted in London in 2002 and 2004 showed that women who were late bookers were more likely to decline an HIV test. 24 It is important to note that we do not have data to distinguish whether women were not tested because the test was not offered by antenatal staff or because women declined or refused testing, which represents a limitation of our study. Additionally, the decline in retesting frequency may be attributed to short intervals between visits for high-risk patients, where retesting may not have been deemed necessary. It is also important to note that we were unable to assess the exact intervals between antenatal visits, which could have influenced whether retesting was performed.

When comparing women who had received ANC and women who had not (i.e., those who presented for pregnancy care for the first time at delivery) in our cohort, the prevalence of HIV was higher in women who had not received ANC during their pregnancy (29%) compared to women who had (22%), suggesting overlapping vulnerabilities around access to health care and HIV risk.

HIVVL monitoring was suboptimal in our cohort, with testing rates below 80% at both the first antenatal visit (84/109, 77%) and delivery (98/137, 71.5%). While the WHO 95-95-95 targets do not cover viral load monitoring, national guidelines recommend that all WLWH have a viral load checked at delivery. Our rate of viral load monitoring was lower than the reported national coverage rate of 88.1%. 2 National data suggest that while ART coverage among pregnant women in South Africa is high, achieving and maintaining viral suppression remains a challenge, with only 74.1% of pregnant women nationally achieving viral suppression. 2 Our cohort's viral suppression rate of 72.4% is in line with these figures, but the fact that over 10% of women delivered with a VL >1000 copies/ml, poses a substantial risk of HIV VT.

The absence of viral load monitoring in almost 30% of women at delivery indicates a concerning missed opportunity for intervention and optimisation of maternal ART. Without a delivery viral load, staff managing these women in the early post-natal period, cannot correctly provide infant prophylaxis or safe feeding advice regarding breastfeeding. The absence of birth PCR results in 21.1% of infants is of equal concern considering their known exposure to HIV during pregnancy. As we did not follow-up neonates beyond the time of delivery, we are unable to ascertain whether any of these infants subsequently accessed PCR testing at their scheduled well-baby follow-up visits at the local primary healthcare facilities.

Our study identified gaps in the monitoring of CD4 counts and the provision of prophylaxis for women with low CD4 counts. South African guidelines recommend CD4 count testing at baseline, 3 months, 12 months, and every 6 months while the CD4 count remains below 200 cells/mm3.19,25 Thus, CD4 count testing may not have been relevant for all women in our cohort, as routine monitoring is not required for those with CD4 counts above 200 cells/mm3. Given that we lacked data on the duration of ART or prior CD4 levels for previously diagnosed women, many may not have been eligible for repeat CD4 testing during pregnancy.

While South African guidelines emphasise targeted CD4 testing, international guidelines provide varying recommendations. For instance, the British HIV Association (BHIVA) guidelines recommend a minimum of one CD4 count at baseline and another at delivery, even in women with CD4 counts above 350 cells/mm3. 26 Additionally, US guidelines suggest that for women with stable HIV, a single CD4 count early in pregnancy may be sufficient. 27 This approach is supported by studies showing that CD4 counts in pregnancy typically drop, but rarely fall below 200 cells/mm3 in women with baseline counts above 450 cells/mm3. 28

The absence of CD4 monitoring in 18.3% of women in our cohort is concerning, particularly in women eligible for TPT or PJP prophylaxis. Missed opportunities for preventive interventions are worrying, considering that HIV-related infections such as tuberculosis contribute substantially to maternal mortality in South Africa. 5 Additionally, studies have shown that women with lower baseline CD4 counts are at increased risk of loss to follow-up (LTFU), further emphasising the need for targeted CD4 monitoring in higher-risk populations. 29 Addressing these gaps in CD4 monitoring and prophylaxis is crucial for improving maternal outcomes in WLWH.

Our findings reflect broader challenges in achieving the 95-95-95 targets in South Africa, particularly in the areas of HIV testing and viral suppression. National data indicate that while 96% of women know their HIV status, only 74.1% achieve viral suppression. 2 This aligns with the gaps we identified in the first and third components of the HIV cascade, with low rates of HIV re-testing and viral suppression. The suboptimal adherence to national VTP guidelines suggests a lack of integration of HIV care and awareness of VTP guidelines amongst the clinical staff in this busy centre. Strengthening staff training and increasing patient education about the importance of HIV testing and viral load monitoring are key steps towards improving adherence to VTP guidelines.

Our findings raise important concerns around the level to which VTP activities are prioritised within a hospital setting. Based on our findings, we need to improve the VTP services offered in our institution and within the clinics that refer to us by investigating why the gaps exist and through the implementation of education campaigns aimed at both patients and healthcare providers.

Limitations

Our study's retrospective nature poses limitations, including incomplete notes from poor record keeping in paper-based files or undocumented testing influencing the results. Additionally, over 95% of the women in our cohort who delivered at CMJAH initially received ANC at a local clinic or referring hospital which may have resulted in incomplete document transfer between facilities. We were unable to assess which ART regimens women were on nor were we able to assess adherence to infant prophylaxis guidelines. These are both areas for future evaluation and research. Furthermore, only 28% of delivery files during the study period were audited, and some files were unavailable, likely due to concurrent audits or missing documentation. This may have introduced selection bias, as certain groups, such as those with neonatal deaths or positive infant PCRs, could be underrepresented. Finally, the study was conducted at a single central referral centre, and the findings may not be fully representative of the broader population.

Conclusion

As was seen in the 2022 ANC HIV survey, there are still gaps along the HIV care cascade. In our cohort, although ART coverage was very high, key gaps continue to be identified for the first and third 95 s. These findings underscore the importance of continuous quality improvement in the VTP programme at our centre, in urban Johannesburg and other similar contexts further afield. Strengthening adherence to HIV (re)testing protocols, viral load monitoring and management of non-suppression, infant birth testing and the provision of prophylactic therapy for those with advanced HIV disease are areas for improvement. Future research is needed to explore barriers to re-testing throughout pregnancy as well as the effectiveness of targeted interventions to enhance implementation of VTP guidelines for WLWH. Addressing the identified gaps is essential if South Africa is to achieve the WHO 95-95-95 targets by 2030, as well as the goal of zero perinatal transmissions.

Acknowledgements

The authors would like to thank the labour ward and records staff at CMJAH.

Footnotes

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical approval: Permission to conduct the study was granted by the Research Committee and Head of the Department of Obstetrics and Gynaecology at CMJAH. Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee (Medical) with clearance certificate M230229/MED23-01-065. The study was also registered on the South African National Health Research Database (GP_202301_033).

Informed consent: This was a retrospective notes review, so informed consent was not required.

Guarantor: JZ

Contributorship: JZ and ND conceived the study. SH, WH and SB were responsible for data collection. JZ and SH cleaned the data. JZ performed statistical analysis. JZ and SH wrote the first draft and all authors (JZ, SH, ND, WH, SB, RN, LC) were involved in the final draft of the manuscript.

References

Articles from Obstetric Medicine are provided here courtesy of SAGE Publications

RESOURCES