TABLE 1.

Summary of the main changes in the South African 2019 prevention of mother-to-child guideline.

Contents	2015 consolidated HIV guideline	2019 PMTCT guideline
Overall approach	-	A renewed focus on the practicality for the end user
		An operational focus on the integration of services, provision of a one-stop service, linkages to care, including care provided in the community by community health workers and other relevant stakeholders
Prevention	-	Guidance on universal infection precautions, and for preventing HIV acquisition in HIV-negative women and sero-discordant couples
Planned pregnancies and safe conception	-	Guidance for family planning and contraception in WLWH, as well as on safer conception
Maternal HIV testing	At first visit, at 32 weeks, and every three months during breastfeeding	At first visit and at every subsequent BANC visit, and three-monthly during breastfeeding
Maternal ART	-	Guidance on adherence messages
		Guidance for the use of DTG in women of childbearing potential
Maternal HIV VL monitoring	Guidelines for newly diagnosed mothers, and WLWH already on ART	Additional guidance for previously ART-exposed mothers
		VL done at delivery and at six months post-partum for all women, and six-monthly during breastfeeding
ART for the mother presenting in labour	Stat dose NVP and TDF/FTC, and AZT three-hourly during labour	Stat dose of NVP and a stat dose of TDF, 3TC, and DTG in a fixed-dose combination (TLD)
		Start ART next day (TLD preferred), after appropriate counselling
Infant HIV testing	HIV PCR test at birth and 10 weeks	HIV PCR test at birth and 10 weeks remain unchanged
		18-week HIV PCR test for high-risk infants removed
		Six-month HIV PCR test for all HIV-exposed infants introduced
	18-week PCR test for high-risk infants who received extended NVP for 12 weeks
		At six months of age, establish the HIV status of all infants not already known to be HIV-exposed by offering an HIV test to the mother. If a maternal HIV test is not feasible, consent should be obtained to perform a rapid HIV test on the child.
	HIV test at six weeks post-cessation of breastfeeding
		Age-appropriate HIV testing at six weeks post-cessation of breastfeeding is retained, with emphasis on testing even if breastfeeding continues for longer than 18 months
		18-month rapid test/ ELISA for all children regardless of HIV exposure (universal testing)
	18-month rapid test for HIV-exposed infants
		HIV PCR test used as a confirmatory test for any HIV-positive result up to age two years
Definition of high-risk infant exposure	Maternal ART for < 4 weeks prior to delivery	High-risk infant at birth:
		Maternal VL ≥ 1000 copies/mL at delivery, or in the last 12 weeks of pregnancy
		No maternal VL result available in the last 12 weeks
		Unknown maternal HIV status because the infant is orphaned or abandoned
	Maternal VL ≥ 1000 copies/mL
		High-risk infant during breastfeeding (> 72 h after delivery):
		New maternal HIV diagnosis during breastfeeding
		Maternal VL ≥ 1000 copies/mL after previous viral suppression on ART
Infant post-exposure prophylaxis	High-risk infants: AZT for six weeks and NVP prophylaxis for 12 weeks	AZT for six weeks and NVP prophylaxis for a minimum of 12 weeks. NVP is stopped after 12 weeks only if the maternal VL is proven to be < 1000 copies/mL. If the maternal VL is not suppressed by 12 weeks, continued NVP is given until maternal VL suppression is achieved, or until four weeks after breastfeeding cessation.
Breastfeeding	Breastfeeding recommended for 12 months (later changed to 24 months)	Breastfeeding recommended for 24 months or longer whilst ensuring maternal ART and viral suppression, in line with recommendations for the general population.

3TC, lamivudine; ART, antiretroviral therapy; AZT, zidovudine; BANC, basic antenatal care; DTG, dolutegravir; FTC, emtricitabine; HIV, human immunodeficiency virus; NVP, nevirapine; PCR, polymerase chain reaction; PMTCT, prevention of mother-to-child transmission of HIV; TDF, tenofovir; TEE, tenofovir, emtricitabine and efavirenz; VL, viral load; TLD, tenofovir, lamivudine and dolutegravir; WLWH, women living with HIV.