Maternal HIV viral load testing during pregnancy and postpartum care in Gauteng Province, South Africa

Background. Pregnant and breastfeeding women living with HIV (WLHIV) are a target population for elimination of mother-to-child transmission of HIV (eMTCT). However, there are limited data on maternal virological responses during pregnancy and the postpartum period in South Africa (SA).Objectives. To review compliance of viral load (VL) testing with national guidelines and suppression rates during pregnancy and up to 9 months postpartum among WLHIV delivering in four tertiary hospitals in Gauteng Province, SA.Methods. All women who had a point-of-care HIV VL test using Xpert HIV-1 VL (Cepheid, USA) at delivery in four tertiary obstetric units in Gauteng between June 2018 and February 2020 were included. HIV VL tests of eligible women performed up to 9 months before and after delivery were extracted from the National Health Laboratory Service’s Corporate Data Warehouse. Proportions of women delivering who had antenatal and postpartum VL tests performed and their suppression rates were determined and expressed as percentages.Results. Of 4 989 eligible WLHIV (median age 31.1 years), 917 (18.4%) had a VL performed during the antenatal period; of these, 335 (36.5%) had a VL ≥50 copies/mL and 165 (18.0%) a VL ≥1 000 copies/mL. At delivery, 1 911 women (38.3%) had a VL ≥50 copies/mL and 1 028 (20.6%) a VL ≥1 000 copies/mL. Among 627 women (12.6%) with a VL test postpartum, 234 (37.3%) had a VL ≥50 copies/mL and 93 (14.8%) a VL ≥1 000 copies/mL. Overall, having a VL test performed during the antenatal period was associated with viral suppression at delivery and receiving a VL test postpartum (p<0.001). Women with a VL ≥50 copies/mL at delivery were more likely to be younger and to remain virally unsuppressed postpartum (p<0.001) compared with women with a VL <50 copies/mL.Conclusions. Fewer than 5% of WLHIV with a VL at the time of delivery received VL monitoring during the antenatal and postpartum periods in accordance with national guidelines. More than 80% of WLHIV delivering had no evidence of VL monitoring during the antenatal period, and they were more likely than women who received monitoring during the antenatal period to be virally unsuppressed at delivery and to receive no VL monitoring postpartum. Women with a high VL at delivery were likely to remain virally unsuppressed postpartum. These results emphasise the need for closer monitoring of and rapid reaction to high maternal VLs during pregnancy, at delivery and postpartum for attainment of eMTCT