Clinical overview
South Africa has the largest HIV programme in the world: approximately 8 million people living with HIV, almost two-thirds of whom are women of reproductive age. Every O&G consultation in this country is, implicitly, an HIV consultation — whether or not the patient knows her status. For the registrar, HIV counselling is not a separate task; it is woven into general gynaecology, antenatal care, contraception, sexual and reproductive health, post-exposure care, and the management of Acute pelvic infection, VBAC, and oncology.
The chapter covers the principles of HIV counselling in a South African public-sector context aligned with the NDoH National Consolidated Guidelines (published January 2026) — which supersede the 2023 ART and 2019 PMTCT guidelines — and the SA HIV Clinicians Society Adult ART Guidelines. It addresses: pre- and post-test counselling (HCT/HTS), HIV transmission and prevention (including PrEP), test interpretation, linkage to ART, the U=U principle, prevention of vertical transmission (PMTCT), occupational and sexual exposure (PEP), and counselling at key clinical transitions (TOP, miscarriage, ectopic, PID, contraception, fertility).
Core knowledge
Epidemiology and transmission
- HIV prevalence in pregnant women in SA: ~30% nationally, with regional variation (KwaZulu-Natal higher).
- Sexual transmission: vaginal, anal, oral (lower risk). Per-act transmission risk varies (vaginal 0.04–0.08%, receptive anal ~1.4%, insertive lower).
- Vertical transmission: without intervention 25–35%; with full PMTCT and viral suppression <1%.
- Parenteral: needlestick ~0.3% per exposure; mucocutaneous lower.
- Breastfeeding: ~10–15% additional transmission without ART; very low with maternal viral suppression.
Modifiers of transmission:
- Viral load (most important — undetectable = untransmissible — U=U).
- Co-existing STIs (ulcerative > non-ulcerative).
- Sexual practices (anal > vaginal > oral).
- Mucosal trauma.
- Stage of HIV (acute infection has high transmission risk).
Testing principles (HTS/HCT)
Consent, rapid testing, confirmation, same-day ART and linkage to care form one counselling pathway.
The "5 Cs": Consent, Confidentiality, Counselling, Correct results, Connection to care.
- Pre-test counselling: explain what HIV is, the meaning of positive and negative results, transmission, prevention, treatment. Confirm consent (opt-out approach widely used).
- Test: rapid antibody test as primary screen (Determine, ABON, etc.). Two different rapid tests confirm; if discordant, send for ELISA + Western blot or PCR.
- Window period: HIV antibody tests detect ~3 weeks post-exposure; 4th-generation antigen/antibody combination tests ~2 weeks; PCR ~10 days.
- Post-test counselling:
- Negative: reinforce prevention, condom use, PrEP if high-risk, repeat in 3 months if recent exposure.
- Positive: confirm with second test, link to care same day where possible, baseline staging (CD4, viral load, TB screening, syphilis, hepatitis B/C, pregnancy test), initiate ART (same-day initiation preferred).
Treatment
First-line ART in South Africa (NDoH 2026): TLD — tenofovir disoproxil fumarate (TDF) + lamivudine (3TC) + dolutegravir (DTG), from 30 kg. Single combined pill. Strong efficacy, high barrier to resistance, well tolerated. (The 2026 guideline renames the tiers TLD 1 / TLD 2 and drops AZT from standard regimens; children use ALD, abacavir-based.)