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.)
For pregnant or breastfeeding women: TLD remains first-line (initial concerns about dolutegravir and neural tube defects from the Tsepamo study have been resolved with longer follow-up — the small signal disappeared, and TLD is recommended for all including pregnancy).
For patients with contraindications: alternative regimens (efavirenz-based, atazanavir/r based) per guidelines.
U=U (Undetectable = Untransmittable)
Multiple landmark studies (PARTNER, PARTNER2, HPTN 052, Opposites Attract) demonstrate that a person on effective ART with sustained undetectable viral load (<200 copies/mL for ≥6 months) does not sexually transmit HIV. This is a cornerstone of counselling — destigmatising, empowering, accurate. It transforms HIV from a transmissible to a manageable chronic condition for compliant patients.
Prevention strategies
Combination prevention:
- Condoms (consistent, correct use).
- ART for the HIV-positive partner (U=U).
- PrEP for HIV-negative individuals at substantial risk.
- PEP for occupational and sexual exposure (within 72 hours, ideally 2 hours).
- Voluntary medical male circumcision (~60% reduction in heterosexual female-to-male transmission).
- STI screening and treatment (reduces co-factor for transmission).
- Behavioural interventions, partner reduction, harm reduction.
Pre-Exposure Prophylaxis (PrEP):
- Tenofovir/emtricitabine (Truvada) daily — oral PrEP.
- Dapivirine vaginal ring — monthly.
- Cabotegravir long-acting injectable (CAB-LA) — every 2 months; in WHO recommendations; expanding access in SA.
- Indications: serodiscordant partner, sex workers, MSM, transgender women, adolescent girls and young women in high-prevalence settings, IV drug users.
- Monitoring: HIV test before initiation and every 3 months, renal function, hepatitis B status.
Post-Exposure Prophylaxis (PEP):
- 28-day course of TDF + 3TC + DTG (or equivalent regimen).
- Start within 72 hours of exposure — earlier is better.
- HIV testing at baseline, 6 weeks, 3 months.
- Indications: occupational needlestick from known/suspected HIV-positive source, sexual assault, sexual exposure to known positive non-suppressed partner.
Prevention of vertical transmission (PVT)
The 2026 National Consolidated Guidelines reframe "PMTCT" as Prevention of Vertical Transmission (PVT); lifelong ART for all HIV-positive pregnant women regardless of CD4 (formerly "Option B+"):
- HIV test at the first antenatal visit; repeat at each scheduled antenatal visit and through breastfeeding if initially negative (a dual HIV/syphilis rapid test where status is unknown).
- Initiate or continue TLD immediately; target viral suppression by delivery; first VL after 3 dispensing cycles; do an antenatal, a delivery, and a postnatal VL.
- Mode of delivery: HIV status alone is not an indication for caesarean — plan vaginal delivery for the suppressed woman; the delivery VL drives infant prophylaxis, not the route.
- Infant prophylaxis (2026): all HIV-exposed infants start dual prophylaxis — NVP once daily + AZT twice daily — from birth until the delivery/maternal VL result is known; higher-risk (maternal VL ≥ 50 c/mL, or unsuppressed/late-diagnosed) → AZT 6 wk + NVP 6 wk, NVP stopped at 12 wk only if maternal VL is then < 50. HIV-exposed infants are no longer given cotrimoxazole (only HIV-infected infants are).
- Infant feeding: exclusive breastfeeding with maternal ART for 6 months; mixed feeding has the highest transmission risk; feeding counselling is context-dependent.
- Infant HIV PCR at birth, 10 weeks, through breastfeeding, and 6 weeks after breastfeeding stops; confirm any positive and start ART promptly.
HIV in gynaecological practice — special considerations
- Cervical screening: HIV-positive women have higher rates of CIN and faster progression to cervical cancer. SA NDoH 2023 protocol: HPV-based screening or cytology starting at HIV diagnosis, every 3 years if normal, more often if abnormal. See cervical-screening-sa.
- STI screening and treatment: lower threshold; comprehensive workup.
- Contraception: most methods compatible with ART; some interactions (efavirenz reduces levonorgestrel implant levels; consider dual method). DMPA injectable — some data suggesting modest increase in HIV acquisition (ECHO trial reassured); DMPA remains available but with discussion of options.
- PID — see acute-pelvic-infection. May be more severe in immunocompromised.
- TB-PID — consider in HIV-positive women with atypical/chronic presentations.
- TOP — see termination-of-pregnancy. HIV status alone is not an indication or contraindication; integrate with HIV care.
- Fertility: HIV-positive women on suppressive ART have largely normal fertility outcomes. Discordant couples: U=U applies; safe natural conception with timed intercourse, or sperm-washing for negative female partner.
Assessment
When to counsel for HIV
- All new antenatal patients (universal testing).
- All gynaecology patients with new diagnosis of STI, PID, TOP, ectopic.
- All sexual assault survivors.
- All women requesting contraception (offer).
- All adolescents at first sexual health consultation.
- Anyone requesting testing.
- Repeat: high-risk patients (sex workers, IV drug users, serodiscordant partners) every 3–6 months; pregnant women at booking and at 32 weeks.
Counselling structure
Pre-test:
- Confirm reason for testing and concerns.
- Brief HIV education (transmission, prevention, treatment).
- Discuss what positive/negative results mean.
- Address fears and stigma.
- Confirm support structures.
- Confirm consent.
Post-test (negative):
- Confirm understanding of result.
- Discuss window period; offer repeat test if recent exposure.
- Prevention counselling: condoms, PrEP, partner testing.
- Plan next test.
Post-test (positive):
- Deliver result clearly, simply, without medical jargon.
- Allow silence and emotional response.
- Explore feelings, support, disclosure plans.
- Discuss U=U as soon as appropriate.
- Same-day staging investigations and ART initiation where possible.
- Address partner notification and disclosure (with safety screening — partner violence risk).
- Link to ongoing care.
- Mental health screening.
Management
The role of the gynaecologist:
- Initiate ART in pregnancy (or refer if not yet trained); routine ART continuation knowledge essential.
- Identify and manage opportunistic infections.
- Cervical screening intensified per HIV-specific protocol.
- Coordinate with HIV clinic for chronic care.
- Address fertility intentions early.
- Integrate contraception with HIV care.
- Recognise treatment failure: rising viral load on ART → adherence counselling, drug-drug interactions, resistance testing if persistent.
- Drug-drug interactions: review every new prescription against ART (especially rifampicin, ergometrine, simvastatin, COC).
Disclosure and partner notification
- Mandatory? No — but encouraged. Voluntary partner notification supported with assisted disclosure.
- Confidentiality: HIV status is sensitive; only share with patient consent except for partner notification (with safety considerations) and infant follow-up.
- Stigma and GBV: assess for partner violence risk before disclosure; have referral pathways.
Mental health
- Depression prevalence 30–40% in HIV-positive women.
- Screen routinely; treat appropriately (avoid efavirenz in patients with active depression — neuropsychiatric side effects).
- Refer to support groups, psychosocial counsellors.
Red flags / pitfalls
- Skipping HIV counselling in non-HIV consultations — universal offer is the norm.
- Failing to address U=U — leaves patient with outdated stigma.
- Disclosure without safety screening — risk of partner violence.
- Stopping ART in nausea of pregnancy — counsel through, consider antiemetic.
- Missing TB screening in symptomatic HIV-positive woman.
- Inadequate ART regimen choice — TLD first-line; document if alternative.
- Poor cervical screening adherence in HIV-positive women — high cancer risk.
- Forgetting PrEP discussion in HIV-negative women at risk.
- Not testing the partner when discordant relationship suspected.
- Inappropriate confidentiality breaches — even to family members, without consent.
- Treating HIV as a single biomedical issue — it is psychosocial, economic, gendered.
Evidence anchors
- National Consolidated Guidelines for the Prevention and Management of HIV in Adults, Adolescents, Children, Infants and Pregnant & Breastfeeding Women (NDoH, published January 2026) — current SA source of truth; supersedes the 2023 ART and 2019 PMTCT guidelines (incorporates the Prevention of Vertical Transmission programme).
- South African HIV Clinicians Society Adult ART Guidelines (2023).
- WHO Consolidated Guidelines on HIV Testing Services.
- WHO Guidelines on PrEP, PEP, treatment.
- PARTNER, PARTNER2, HPTN 052, Opposites Attract studies (foundation of U=U).
- Tsepamo Study — dolutegravir safety in pregnancy.
- ECHO Trial — DMPA and HIV risk.
- BHIVA Pregnancy Guidelines.