Management of HIV in  pregnancy  Sarah Blackstock

 Management of HIV in pregnancy Durban, South Africa Sarah Blackstock
Sarah Blackstock 200028239 Elective report
I undertook my elective in two contrasting settings New Zealand and South Africa. I
observed both first and third world pathologies and facilities and undertook a project to
enhance my learning.
For the purpose of this assignment I will focus on my project which was undertaken at King
Edward VIII Hospital in Durban. This is a government funded tertiary hospital.
To organise a project careful planning and collaboration with supervisors in both Durban and
Leeds was necessary prior to arrival. I undertook a project that Professor Mhlanga –
Head of the Department of Obstetrics and Gynaecology at King Edward Hospital felt would
be useful to the department and would provide a valuable learning experience for myself. I
am grateful to have received two bursaries: the RCOG/Wellbeing of Women Student Elective
Bursary and the University of Leeds Centenary & Hardwick Award. On return I also
presented my findings at the University of Leeds Division of Obstetrics and Gynaecology
Postgraduate Regional Meeting on the 6th November 2008.
“To evaluate the management of HIV in pregnancy in Durban, South Africa.”
To observe the management of HIV in pregnancy in Durban, South Africa.
To analyse the current protocols for management of HIV in pregnancy.
To study the challenges of HIV to maternal and obstetric care.
To identify any limitations to management of HIV in pregnancy when care is
provided in a resource-limited setting.
I will observe and assist in patients care at antenatal clinics, in delivery suite and
theatre, following through patients wherever possible to view outcomes.
I will access protocols and compare local guidelines in South Africa to those being
practised at the hospital.
I will access available statistics from the maternity database to elicit how successful
the local service is.
I will discuss with Doctors, Midwifes and Nurses their role in the management of
complications of HIV in pregnancy, asking them to highlight the challenges they face.
2 Sarah Blackstock 200028239 I will discuss with patients their perceptions of HIV in pregnancy and services
Durban is a large city in Kwa Zulu Natal province that is at the epicentre of the HIV
epidemic. The Prevalence of HIV-1 at Antenatal care is 37.4%.1 HIV infection has a
significant negative impact on maternal and neonatal outcomes.2
Figure 1: National HIV prevalence trends among antenatal clinic attendees, South Africa,
1990 to 2007.3
Figure 2: HIV prevalence estimates by province among antenatal clinic attendees, South
Africa. 2007.1
3 Sarah Blackstock 200028239 Results
Overall Durban is performing well on many maternal health indicators. The antenatal care
attendance has remained over 90% since 1998, in line with national levels.3 Currently 92% of
deliveries are conducted by skilled health workers.4
Treatment protocol:
King Edward VIII Hospital has adopted the Prevention of Mother to Child transmission
(PMTCT) strategy.5 Women are counselled and encouraged to receive a free rapid finger
prick HIV test. Currently this service is separate to antenatal care however all women are
encouraged to undergo testing.
Figure 3: PMTCT Protocol at King Edward VIII Hospital.6
4 Sarah Blackstock 200028239 Figure 4: Antenatal Clinic and PMTCT Clinic at King Edward VIII
Figure 5: VCT Room
Figure 6: A busy Antenatal clinic
5 Sarah Blackstock 200028239 Treatment Regime
Mothers not currently on Anteretrovirals (ARVs):
Start AZT at week 28 or as soon as possible thereafter unless they are
anaemic. They also take a single dose of nevirapine at the onset of
Women already taking ARVs when pregnancy is confirmed:
If they are taking efavirenz, this is switched to nevirapine in the first
If pregnancy is confirmed after this point, an efevairenz switch is no
longer necessary but a foetal anomaly scan is recommended due to
the possible adverse effects of efavirenz exposure on the foetus during
the first trimester.
Women with CD4 counts < 200 or at WHO stage IV:
Start three-drug antiretroviral therapy (HAART) and cotrimoxazole
prophylaxis. The triple therapy is with Stavidine, 3TC and AZT.
Figure 7: Treatment regime at King Edward VIII Hospital.6
Caesarean sections are not routinely performed. Labour is managed using an aseptic
technique and management is as minimally invasive as possible.
After delivery infants receive a single dose of nevirapine and seven days of azidothymidine
(AZT). AZT should be given for 28 days if the mother received less than four weeks of AZT
or Highly Active Antiretroviral Therapy (HAART) during pregnancy. Infant feeding options
are also discussed with mothers. A follow up for the mother and baby is undertaken 6 and 18
months as well.
Figure 8: Management if HIV in Labour at King Edward VIII Hospital.6
Figure 9: Delivery suite
Figure 10: Exclusive Breast-feeding poster
Antenatal services have been free since 1994 and although high numbers attend antenatal
care at King Edwards, many women attend late or only attend one visit.7 One study in Durban
found 47.9% presented for formal ‘booking’ late, at a gestational age of six months after the
last menstrual period.7 This limits the quality of care provided and may reduce the amount of
women able to start ARVs. The antenatal clinics at King Edwards were under resourced and
overstretched. Consequently some women perceived the services as poor and did not see the
health benefits of attending antenatal care.8
6 Sarah Blackstock 200028239 At King Edwards currently 71% of women undertook Voluntary Counselling and Testing
(VCT) at their first antenatal visit in 2007 and 83% of eligible women accepted antiretroviral
prophylaxis with AZT.3,9Although HIV testing is free patients are charged for CD4 counts,
therefore many women eligible for HAART have not had the opportunity to receive it.
Furthermore 60% of those mothers assessed for HAART had not yet received it. One of the
requirements for starting treatment is having a ‘buddy’ to support you through treatment;
many women did not have a suitable friend, limiting their access to treatment.9,10,11
Neviripine prophylaxis uptake among known HIV positive mothers during labour has
dramatically increased of recent times and is now 100%. However, the amount of women
who attend labour ward already taking HIV treatment is significantly lower.3,9
Transmission rates
Over 60% of women in delivery suite are known to be HIV positive, higher than the national
average, this is due to the fact that is a tertiary centre where more complex cases are seen.3
Despite the PMTCT programme, data gathered at childhood immunisation clinics in Kwa
Zulu Natal found that 20.8% of HIV-exposed infants had become HIV-infected.
However research has shown transmission rates should be much lower (around 11.9%), if
every woman with HIV had been identified and every HIV-positive pregnant women and
exposed child had been given antiretroviral prophylaxis.9
Despite the introduction of the PMTCT programme maternal and child mortality have not
Currently in South Africa the emphasis has been on improving the coverage of the PMTCT
programme rather than improving the intervention offered, this study highlights that coverage
and uptake in Kwa Zulu Natal is now high, suggesting that the programme is ready to do
South Africa should adopt the more efficacious treatment regime recommended by the World
Health Organisation (WHO). This regime consists of seven days of AZT and 3TC for
mothers postpartum after the single dose Nevirapine at the time of delivery. HAART is also
recommended for all pregnant women in WHO stage 3 disease with a CD4 count below 350
cells/mm3.13 A combination treatment would reduce the risk of HIV transmission and
decrease the risk of resistance developing.14
South Africa has been accused of being “a middle income country behaving like an economic
basket case,” as HIV treatment is out of step with poorer and less well resourced nations.9
Rwanda, which finances the majority of its health sector from international donor aid, began
to implement the AZT/3TC postpartum regimen for mothers and infants in September 2005.13
7 Sarah Blackstock 200028239 Antenatal care
The WHO recommend the first antenatal visit to be before 16 weeks gestation, currently
many mothers at King Edwards attend later than this.15 Consequently many eligible women
are receiving optimal care. To resolve this issue health promotion is needed to increase
awareness and understanding regarding their importance.
Integration of services
Increased integration between antenatal care and postnatal services is necessary to ensure all
eligible mothers and infants receive treatment and their condition is monitored. Integrated
mother and child health cards could be useful for continuity of care and enabling mothers and
children to get back into care.11
Currently women are not routinely screened for opportunistic infections and consequently
these complications are discovered late. Screening tools should be provided at antenatal
clinics and a high index for suspicion should also be taken during delivery and postnatally.16
The majority of maternal mortality occurs postnatally, however currently no follow up is
undertaken. An Audit at King Edward’s highlighted that the majority of women with
fulminating sepsis presented between the sixth and tenth days post partum. Therefore a
review of mothers at six days postpartum would be beneficial.16
HIV is a leading cause of maternal mortality in South Africa. King Edward VIII hospital has
adopted the PMTCT strategy and in line with the rest of Kwa Zulu Natal Province is
performing well on many maternal care indicators. Despite this maternal and child mortality
have not decreased. Adopting the WHO recommended treatment regime and providing
follow up postnatally could improve outcomes and reduce maternal and child mortality.
Personal development
Undertaking the elective significantly supported my personal development. I developed my
organisation and planning skills and learnt how to write research proposals for potential
bursaries, this will be beneficial for my future career. I gained knowledge of the management
of HIV in pregnancy and its complications; this will inform my future practice as a potential
Obstetrics and Gynaecology doctor. I developed my clinical skills and gained ‘hands on’
experience which will improve my confidence as a medical student and junior doctor. Being
involved in the management of acutely sick patients and seeing the devastating effects of HIV
in pregnancy are lifelong memories that will stay with me through my future career. I learnt
the importance of prevention strategies and Public Health interventions to tackle HIV. In
England HIV in pregnancy rarely causes maternal or child mortality, however in South Africa
8 Sarah Blackstock 200028239 I saw the impact of limited resources and importance of good Obstetric and Gynaecologic
care. HIV in pregnancy in the UK is increasing, and many of these cases are in women from
Sub Saharan Africa. Understanding the complexities of HIV management and sociocultural
issues regarding this disease will be invaluable for providing good care. Whilst in South
Africa I also improved my communication skills and awareness of providing care to patients
from a different culture; these are transferable skills which will improve my future patient
1. The National HIV and Syphilis Survey South Africa. 2007. National Department
of Health South Africa 2008.
2. Rollins N, Coovadia H, Bland R, Coutsoudis A, Bennish M. Pregnancy outcomes
in HIV-infected and uninfected women in rural and urban South Africa. JAIDS
2007; 44(3):321-328.
3. King Edward VIII Hospital Maternal Health Statistics Database. Accessed
4. Beksinska M, Kunene B, Mullick S. South African Health Review. October 2006.
5. National Department of Health. Policy and Guidelines for the Implementation of
the PMTCT programme. Republic of South Africa. February 2008.
6. King Edward VIII Hospital PMTCT Protocol. 2005
7. Sibeko S, Moodley J. Health Care Attendance Patterns By Pregnant Women In
Durban, South Africa. SA Fam Pract. 2006; 48(10):17.
8. Myer L, Harrison A. Why Do Women Seek Antenatal Care Late? Perspectives
From Rural South Africa. J Midwifery Women’s Health 2003; 48:268–272.
9. Audit of high infant mortality in Durban Hospitals illustrates delivery gap
remaining for PMTCT and Paediatric ART programmes. 12/6/2007. Accessed 10th October 2008.
10. Department of Health. National Antiretroviral Treatment Guidelines. Republic of
South Africa. 2004.
11. Sepitloane HM, Miller NL, Wennberg JL. Evaluation of the PMTCT programme
in providing effective care to HIV-infected pregnant women in sentinel sites in
Kwa Zulu Natal. AIDS 2006, XVI International AIDS conference: Abstract no.
12. Ramogale MR, Moodley J, & Sepitloane HM. HIV related maternal mortalityprimary causes of death at King Edward VIII Hospital, Durban/South African
Medical Journal. 2007; 97(5):363-366.
13. World Health Organisation. Antiretroviral drugs for treating pregnant women and
preventing HIV infection in infants: towards universal access. Recommendations
for a public health approach. August 2006.
14. Alcorn K. South Africa: updated PMTCT guidelines still lag behind international
standards, say experts. February 2008. Accessed 10/10/08.
15. Villar J, Bergsjø P. WHO Antenatal Care Randomized Trial: Manual for the
Implementation of the New Model. WHO. 2001.
9 Sarah Blackstock 200028239 16. Sepitloane HM, Mhlanga RE. Changing patterns of maternal mortality (HIV/AIDs
related) in poor countries. Best Pract Res Clin Obstet Gynaecol. 2008; 22(3):489 499.