Much ado over the new South African PMTCT Guidelines

A group of well-respected South African academics and HIV experts have started a national debate by questioning the ‘dangerously hasty’ acceptance and implementation of lifelong antiretroviral therapy (ART) for HIV-positive pregnant women in resource-constrained settings. The South African National Department of Health will introduce updated prevention of mother-to-child transmission (PMTCT) guidelines this month, based in part on the World Health Organization (WHO)’s recommendations on the use of ART for treating pregnant women and preventing HIV infection in infants. The guideline update will recommend a standardised triple-drug regimen to treat HIV-infected pregnant women (regardless of CD4 count) during pregnancy and breastfeeding, with continuation of ART after breastfeeding for women with CD4 counts less than 350 (Option B). HIV-exposed infants will receive nevirapine prophylaxis for 4 - 6 weeks and should be tested for HIV at 6 weeks of age. The new treatment guidelines are expected to further enhance the success of the PMTCT programme in South Africa (HIV transmission from mother to child is down from 8.0 - 20.2% prior to 2007, to 3.5% in 2010), with the goal being the complete elimination of preventable HIV infection in infants. More critically, it will bolster a concerted effort to reduce high maternal morbidity and mortality figures; HIV, complicated by accompanying infections such as tuberculosis, pneumonia and meningitis, is responsible for 40% of maternal deaths in South Africa. Further guidance on treatment options for pregnant women, including a stronger recommendation to offer all pregnant women lifelong ART irrespective of CD4 count (Option B+) is expected in the form of revised WHO guidelines in June.