Clinical overview
HIV in pregnancy is, for the South African registrar, not a sub-speciality interest but the central thread running through almost every antenatal clinic you will run. South Africa carries one of the largest antenatal HIV burdens in the world, and HIV — counted under non-pregnancy-related infections — has historically been one of the leading underlying causes of maternal death in the Saving Mothers reports of the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD). The story of the last two decades is, however, one of remarkable success: a comprehensive, universal-treatment programme has driven the vertical (mother-to-child) transmission rate from a catastrophic level in the untreated era down to a low single-figure percentage, and to well under 1% in women who are virally suppressed at delivery.
Your task is therefore twofold and you should hold both in mind at once. First, prevent vertical transmission — get every pregnant woman tested, every positive woman onto effective antiretroviral therapy (ART) as fast as possible, suppress her viral load before delivery, and protect the infant peripartum and during feeding. Second, keep the mother alive and well — HIV is a chronic disease that interacts with anaemia, tuberculosis, opportunistic infection, pre-eclampsia and the surgical risks of caesarean section. The framework that operationalises all of this is the Prevention of Vertical Transmission (PVT) programme — the term the current guideline uses in place of the older "PMTCT" — embedded in the National Consolidated Guidelines for the Prevention and Management of HIV in Adults, Adolescents, Children, Infants and Pregnant & Breastfeeding Women (NDoH, published January 2026) and the National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024). The January 2026 Consolidated Guidelines are the current source of truth and supersede both the 2023 ART Clinical Guidelines and the 2019 PMTCT guideline; the specifics in this chapter are taken from them. This chapter is built around the verb in the objective — manage — so it weights assessment and the practical management cascade heavily, while grounding you in the core knowledge that makes those decisions make sense. It connects closely to hiv-counselling, antenatal-booking and antenatal-screening, and to the infant side at infant-feeding.
Core knowledge
Vertical transmission: when and how
Mother-to-child transmission occurs in three windows: in utero (transplacental, mostly late pregnancy), intrapartum (the largest contributor in the untreated woman — exposure to maternal blood and genital secretions during labour and delivery), and postnatally through breastfeeding. The single dominant driver of transmission across all three windows is maternal plasma viral load; the higher the viral load, the higher the risk, and an undetectable viral load on suppressive ART renders the in-utero and intrapartum risk very low. This is why the entire programme is organised around achieving and maintaining viral suppression rather than around the older era's intrapartum-only interventions.
Other factors that increase transmission risk include low CD4 count / advanced disease, acute (recent) HIV infection during pregnancy or breastfeeding (very high viral load during seroconversion), prolonged rupture of membranes, chorioamnionitis, invasive procedures, prematurity, and mixed feeding in the breastfeeding period (mixed feeding damages gut mucosa and carries a higher transmission risk than exclusive feeding of either kind).
First-line ART in South Africa
The South African first-line regimen for adults, including pregnant and breastfeeding women, is TLD — a single fixed-dose combination of tenofovir disoproxil fumarate (TDF) + lamivudine (3TC) + dolutegravir (DTG) (NDoH National Consolidated Guidelines, 2026). The 2026 guideline drops the TDF weight-eligibility threshold from 35 kg to 30 kg, and renames the regimen tiers: what used to be "first-line" and "second-line" are now TLD 1 (DTG-containing, never failed another regimen) and TLD 2 (DTG-containing, failed an earlier regimen). Dolutegravir, an integrase strand-transfer inhibitor, is potent, fast-acting (rapid viral-load decline), has a high barrier to resistance and is well tolerated, which makes it ideal in pregnancy where speed of suppression before delivery matters. The early peri-conception neural-tube-defect signal was not confirmed on longer follow-up (Tsepamo), so DTG/TLD is now first-line throughout pregnancy and in women of childbearing potential — there is no longer any efavirenz-based caveat, and the guideline explicitly simplifies switching from the old TEE (TDF + emtricitabine + efavirenz) regimen to TLD without waiting for a viral load. Note two further 2026 changes: zidovudine (AZT) is no longer part of any standard adult ART regimen (reserved for renal failure plus abacavir hypersensitivity, or for preterm neonates), and the preferred paediatric regimen is now ALD (abacavir + 3TC + DTG).
Universal "test and treat" applies: every HIV-positive pregnant woman starts ART regardless of CD4 count or clinical stage — ideally same-day, and within 7 days at the latest (pregnant women are a rapid-initiation priority group) — and ART is lifelong. The CD4 count is still measured at baseline because it identifies the woman with advanced HIV disease (CD4 ≤ 200 or WHO stage 3/4) who needs additional opportunistic-infection screening and prophylaxis, but it is no longer a gate to starting treatment.
Figure I12.1 — The Prevention of Vertical Transmission (PVT) cascade under the 2026 Consolidated Guidelines: antenatal entry and testing, TLD with viral-load-led monitoring, intrapartum care, and infant prophylaxis with feeding.
Assessment
Testing — the entry point to everything
Provider-initiated HIV testing is offered to every pregnant woman at the first antenatal visit (booking), framed as opt-out, with appropriate pre- and post-test counselling (see hiv-counselling and antenatal-screening). A woman who tests negative is re-tested at each scheduled antenatal visit and through breastfeeding, because incident (new) infection in pregnancy or lactation carries a very high transmission risk and is a recognised gap in the prevention cascade. Rapid antibody tests are the screening platform (a dual HIV/syphilis rapid test is used where HIV status is unknown), with confirmatory algorithms per the national HIV testing services policy.
Assessing the newly diagnosed pregnant woman
When a woman is confirmed HIV-positive, work systematically:
- Confirm the diagnosis and establish whether she is newly diagnosed, known positive and on ART, or known positive but defaulted.
- Baseline bloods: CD4 count (graded for opportunistic-infection prophylaxis, with an automatic laboratory reflex cryptococcal antigen (CrAg) on any CD4 < 200 — and in a pregnant woman a positive CrAg means lumbar puncture regardless of symptoms), HIV viral load, creatinine (TDF is nephrotoxic and renally cleared; in pregnancy the guideline assesses TDF eligibility on the absolute serum creatinine — acceptable if < 85 µmol/L — rather than a calculated eGFR), haemoglobin/full blood count (treat iron deficiency; refer if Hb < 8 g/dL with symptoms, or any anaemia diagnosed at ≥ 36 weeks), and hepatitis B surface antigen (TDF + 3TC also treat hepatitis B — important for the regimen and because of flare risk if TDF is ever stopped).
- Screen for tuberculosis: a symptom screen (current cough, fever, night sweats, weight loss) at every visit, plus a routine TB-NAAT (Xpert) at the time of HIV diagnosis and at antenatal enrolment regardless of symptoms in a pregnant woman. TB is the commonest serious co-infection and a major contributor to maternal death; a positive screen mandates investigation, and TB preventive therapy is offered to eligible women.
- Screen for other co-infections and the rest of the antenatal package: syphilis, and the standard booking screen (see antenatal-booking).
- Establish treatment history: regimen, adherence, any prior regimens or treatment failure, and resistance concerns — this drives whether she stays on first-line or needs specialist input.
Monitoring on treatment
The two questions you keep asking are is she taking it and is it working. Viral load is the central monitoring tool. Under the 2026 guideline the first viral load after starting ART is taken at 3 dispensing cycles (roughly 3 months, replacing the old 6-month timing — the creatinine check moves to month 3 too). Pregnancy gets its own VL touch-points, recorded under three dedicated codes — an antenatal, a delivery, and a postnatal viral load — because the delivery viral load drives the infant's prophylaxis (see below), so it must actually be done. "Suppressed" is a viral load below 50 copies/mL. Virological failure is defined as two or more viral loads ≥ 1000 copies/mL after at least 9 months on a DTG-containing regimen, with two documented enhanced-adherence interventions in between. A detectable or rising viral load triggers enhanced adherence counselling first (resistance to DTG is uncommon — most apparent failure is adherence), then a repeat VL; a switch off a DTG-containing regimen should happen only after InSTI resistance is confirmed on a resistance test, not on viral load alone.
Management
The management of HIV in pregnancy is best held as a cascade across four phases: antenatal, intrapartum, the infant, and postnatal/feeding. Match the intervention to where in the cascade the woman is.
Antenatal management
- Start ART immediately in any newly diagnosed woman — same-day initiation where she is ready — using TLD as first-line. Speed matters because the time available to drive the viral load down before delivery is finite.
- A woman already on ART and suppressed continues her regimen; do not interrupt effective therapy. A woman who has defaulted is restarted promptly with intensive adherence support.
- Adherence support is the core therapeutic act, not an add-on — disclosure support, partner testing, addressing pill burden, follow-up of missed visits. Suppression is impossible without it.
- Co-trimoxazole prophylaxis (CPT) for women with advanced HIV disease (CD4 ≤ 200 or WHO stage 3/4), stopped once the CD4 recovers above 200. TB preventive therapy (TPT) — isoniazid 300 mg daily for 12 months with pyridoxine 25 mg — for the pregnant woman with advanced HIV disease (after excluding active TB and contraindications). Manage co-infections, and remember the 2026 syphilis schedule that runs alongside HIV care: rapid treponemal testing at booking and repeated through pregnancy.
- Integrate HIV care with the rest of high-risk antenatal care (see high-risk-pregnancy-risks): HIV-positive women warrant attention to anaemia, growth, and infection.
Intrapartum management
- For a woman who is virally suppressed on ART, plan vaginal delivery as the default — HIV status alone is not an indication for caesarean section, and CS carries its own maternal morbidity and infective risk in this population. Continue her oral ART through labour.
- For a woman with a high or unknown viral load near term (presenting late, defaulted, or unsuppressed), the balance shifts toward reducing intrapartum exposure and getting drug on board fast. The 2026 intrapartum action for the unsuppressed/unbooked woman is concrete: give a stat dose of TLD and a stat dose of nevirapine (NVP) in labour, and ensure her ART is continued afterwards. The role of elective caesarean section purely to reduce transmission is far less important than in the pre-ART era and HIV status alone is not a CS indication; a high delivery viral load is simply the situation in which the intrapartum drug dose and infant prophylaxis matter most.
- General intrapartum discipline reduces transmission: avoid unnecessary invasive procedures (fetal scalp electrodes, fetal blood sampling, prolonged rupture of membranes, routine episiotomy and instrumental delivery) where avoidable, and manage labour expeditiously.
The infant
- Infant antiretroviral prophylaxis (2026 model — learn this, it changed). Because prophylaxis depends on the mother's delivery viral load and that result is rarely back at birth, every HIV-exposed infant now starts dual prophylaxis — nevirapine (NVP) once daily and zidovudine (AZT) twice daily — from birth, continued until the delivery/maternal viral load result can be reviewed. The infant is then classified by that result:
- Lower-risk (mother stably suppressed, VL < 50): the dual prophylaxis can be stopped once the suppressed VL is confirmed.
- Higher-risk — the threshold for "higher-risk" dropped from a maternal VL ≥ 1000 to ≥ 50 copies/mL (also: unsuppressed, newly/late-diagnosed, or not on effective ART): give AZT for 6 weeks and NVP for 6 weeks; if the baby is breastfeeding and the mother is not suppressed, NVP is extended and only stopped at 12 weeks if the maternal VL is then < 50.
- Cotrimoxazole (CPT): HIV-exposed infants are no longer started on CPT under the 2026 guideline — only HIV-infected infants remain eligible. (This is a common exam trap now.)
- Early infant diagnosis uses HIV PCR (nucleic-acid testing), because maternal antibodies cross the placenta and make antibody tests uninterpretable in the young infant. PCR is performed at birth, again at around 10 weeks, through the breastfeeding period, and 6 weeks after breastfeeding has stopped, with confirmatory testing of any positive result and prompt ART initiation in an infected infant. See infant-feeding for the feeding–testing interface.
Figure I12.2 — The 2026 HIV-exposed-infant prophylaxis map: dual NVP + AZT from birth until the delivery VL is reviewed, lower- vs higher-risk stratification at maternal VL 50, the PCR schedule, and the no-cotrimoxazole rule for exposed infants.
Postnatal and feeding
- The mother continues lifelong ART — pregnancy does not change the lifelong nature of treatment; reinforce that ART continues for her own health and to protect future pregnancies and her infant during breastfeeding.
- Feeding: in the South African context the policy supports exclusive breastfeeding for the mother on ART, because exclusive breastfeeding combined with maternal viral suppression carries a low transmission risk and confers major survival benefit in our setting, and because mixed feeding is more dangerous than either exclusive option. The cardinal rule is avoid mixed feeding (see infant-feeding).
- Postpartum contraception and ongoing engagement in care are part of the discharge plan (link to postpartum-contraception in the complicated-obstetrics domain); the immediate postnatal period is a notorious point of disengagement from HIV care.
Emergency: the unbooked, unsuppressed woman in labour
This is the high-stakes scenario the examiners love and the one where infants are lost. The drill, when an HIV-positive woman of unknown or high viral load presents in established labour:
- Confirm HIV status immediately with a rapid test if status is unknown — do not wait. (Use a dual HIV/syphilis rapid test where status is unknown.)
- Give maternal ART now — a stat dose of TLD plus a stat dose of nevirapine in labour, then continue daily TLD.
- Minimise intrapartum exposure — avoid invasive monitoring and procedures, manage labour efficiently.
- At delivery, start the baby on dual prophylaxis (NVP once daily + AZT twice daily) immediately — this is a higher-risk infant — and register it for early infant diagnosis with a birth PCR.
- Do not lose the dyad to follow-up — arrange maternal ART continuation, infant prophylaxis supply, feeding counselling and a return date before discharge.
The principle: every hour and every missed dose in the unsuppressed woman raises the infant's risk, so act fast, give ART, protect the infant, and secure follow-up.
Figure I12.3 — Emergency drill for the unbooked or unsuppressed woman in labour: rapid testing, stat TLD + stat NVP, minimise exposure, immediate infant dual prophylaxis, and securing the dyad in follow-up.
Red flags / pitfalls
- Treating HIV status as an indication for caesarean section in a suppressed woman. It is not. Default to vaginal delivery in the suppressed woman; reserve CS for obstetric indications or the genuinely unsuppressed/high-viral-load scenario per guideline.
- Forgetting the seroconverting woman. A negative test at booking is not a clean bill for the whole pregnancy. Acute infection in pregnancy or lactation carries a very high viral load and transmission risk — re-test through pregnancy and breastfeeding.
- Stopping ART after delivery. ART is lifelong. The postpartum period is the commonest point of disengagement; build the continuation plan into discharge.
- Mixed feeding. Counsel hard against it — it carries a higher transmission risk than exclusive breastfeeding or exclusive formula feeding.
- Missing TB. TB is the leading serious co-infection and a major maternal-death contributor — symptom-screen at every contact.
- Ignoring renal function on TDF. Tenofovir is nephrotoxic; check the creatinine/eGFR at baseline and on monitoring.
- Using an antibody test to diagnose the neonate. Maternal antibody crosses the placenta — early infant diagnosis is by HIV PCR, not antibody.
- Treating a detectable viral load as automatic resistance. Most apparent failure is non-adherence. Enhanced adherence counselling and a repeat viral load come before assuming resistance and switching regimens.
- Working from a superseded edition. The figures here are from the January 2026 Consolidated Guidelines; if you trained on the 2019/2023 documents you will get the infant-prophylaxis model (now universal dual NVP + AZT), the "higher-risk" threshold (now maternal VL ≥ 50), the exposed-infant CPT rule (now not given), and the first-VL timing (now 3 dispensing cycles) wrong. Always confirm you are reading the current edition.
- Giving an HIV-exposed infant cotrimoxazole reflexively. Under the 2026 guideline only HIV-infected infants get CPT; HIV-exposed infants do not.
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) — the current SA source of truth for HIV and the Prevention of Vertical Transmission (PVT) programme. Supersedes the 2023 ART Clinical Guidelines and the 2019 PMTCT guideline. Source of the specifics in this chapter: TLD first-line from 30 kg including pregnancy; simplified TEE→TLD switch; first VL at 3 dispensing cycles; virological failure = two VLs ≥ 1000 after ≥ 9 months on DTG; universal infant dual NVP + AZT prophylaxis until the delivery VL is known; higher-risk infant threshold maternal VL ≥ 50; HIV-exposed infants not on CPT; stat TLD + NVP intrapartum for the unsuppressed woman.
- National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024) — the SA obstetric source of truth; integrates PVT into antenatal, intrapartum and postnatal care.
- Southern African HIV Clinicians Society (SAHCS) Adult ART Guidelines (2023) — adult ART reference, consistent with the DTG-based national regimen (defer to the 2026 national guideline where they differ).
- South African Saving Mothers Report (NCCEMD) — triennial confidential enquiry; non-pregnancy-related infection (HIV-associated) historically a leading underlying cause of maternal death (cite the latest triennium).
- WHO Consolidated Guidelines on HIV (testing, treatment, prevention; current) — international alignment on test-and-treat, dolutegravir-based first-line and vertical-transmission prevention.
- National Cervical Cancer Screening guidance — relevant because HIV-positive women are screened at HIV diagnosis and more frequently regardless of age; integrate cervical screening into HIV care (see cervical-screening-sa).