1. Characterizing viral load burden among HIV-positive women around time of delivery: Findings from four tertiary obstetric units in Gauteng, South Africa
Faith Moyo

2. Conflict of Interest
No disclosure

3. Acknowledgements Paediatric HIV Surveillance group
NICD: Prof Gayle Sherman, Dr Ahmad Haeri Mazandarani, Dr Tendesayi Kufa, Sr Moipone Piliso, Ms Aurélie Mukendi, Dr Tanya Murray,
NHLS: Prof Sergio Carmona
Charlotte Maxeke Johannesburg Academic Hospital
Sr Lerato Mthombeni, Sr Beverley Letsoalo, Dr Coceka Mnyani, Dr Natalie Odell, Prof Mphele Mulaudzi
Chris Hani Baragwanath Academic Hospital
Sr Ntaoleng Moreko, Rebecca Kgame, Prof Yasmin Adam, Dr Vuyelwa Baba, Dr Firdose Nakwa, Dr Alison van Kwawegen
Kalafong Provincial Tertiary Hospital
Sr Nkele Selepe, Sr Khensani Phelane, Dr Felicia Molokoane, Dr Valerie Vannevel, Dr Khomotso Masemola, Dr Derisha Pillay, Dr Marike Boersema, Prof Nicolette du Plessis, Dr Khosi Ngobese
Rahima Moosa Mother and Child Hospital
Prof Karl-Günter Technau, Sonjiha Khan, Lebo Phakathi
Funding:
-This project is made possible thanks to Unitaid’s support through a grant to CHAI/UNICEF. Unitaid accelerates access to innovation so that critical health products can reach the people who most need them.

4. Background: PMTCT in South Africa
1 in 3 pregnant women in South Africa is HIV-positive
Antiretroviral therapy (ART) initiation rate amongst antenatal clinic clients is >95% in the public health sector
VL suppression rates in HIV-positive, pregnant and post partum women are not well documented
Maternal VL suppression critical to:
◦ Maternal & neonatal health
◦ MTCT of HIV
◦ Maternal & neonatal death

5. Monitoring Early Infant Diagnosis in SA
6 week MTCT rate
Birth (<7 days) MTCT rate
Graphs: Sherman G et al;

6. Road to eMTCT in South Africa
Number of women conceiving on ART increasing
-universal test & treat strategy
IU transmission rate <1.0%
Equates to 247 cases/ live births (WHO eMTCT target = <50 cases/ live births or <5% in breastfeeding populations)
eMTCT efforts challenged by:
Poor VL monitoring in pregnancy & postpartum
-limited information on VL suppression rates among pregnant and breastfeeding HIV-positive women
High rates of seroconversion in pregnancy & during breastfeeding
Road to eMTCT in South Africa
Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive.

7. Potential eMTCT Game Changers: Point of Care HIV VL & EID testing
Centralized routine laboratory HIV VL & EID testing remains standard of care in South Africa
Point of care (PoC) HIV VL (for mothers) & EID (for infants) testing have potential to:
↓ result turn-around times & ↑ result return-rate
↑ interventions to improve viral suppression and early ART initiation/initiate high risk infant prophylaxis

8. Study Objective
To describe maternal VL burden and intra-uterine transmission rates among HIV-positive pregnant women and their HIV-exposed neonates using PoC testing around time of delivery at four tertiary obstetric units in Gauteng, South Africa

9. Methodology
Study sites: 4 tertiary obstetric units in Gauteng province
(3 Johannesburg sub-districts and 1 in Tshwane Metro)
Study period: June 2018-Mar 2019
Specimen handling:
Specimen collection performed by doctors & nurses as part of routine care
Testing conducted by PoC operators (mostly nurses) on weekdays, between 08h00-16h00

10. Methodology: Procedures
All HIV-positive mothers admitted to labour/ postnatal wards
Infants
Offered PoC EID
PCR Positive
Confirmatory tests done on same sample + 2nd sample
Referred for care
PCR Negative
Reassured and counselled to return for testing at 10wks
Mothers
Offered PoC VL
VL ≥1 000 copies/mL
Adherence counselling for mother
High risk prophylaxis for infant
VL <1 000 copies/mL
Mother reassured about VL suppression
Low risk prophylaxis for infant
Slide: Dr T Kufa, Centre for HIV & Sexually Transmitted Infections, NICD

11. Site of Tertiary Obstetric Unit
Findings
Table 1. Maternal Viral Load and Early Infant Diagnosis PCR testing around time of delivery: Results from a point-of-care study at four tertiary obstetric units in Gauteng, South Africa.
N, number; VL, viral load; EID, early infant diagnosis; cps/ml, copies per millilitre; PCR, polymerase chain reaction; IU, intra-uterine; PoC, Point-of-care; JHB, Johannesburg; *Median VL= 24 600 copies/mL (IQR: 6 380–82 100)
Maternal PoC VL
Neonatal PoC EID
Routine Setting
Site of Tertiary Obstetric Unit
Live births to
HIV-positive woman
Valid VL result
N (%)
Median VL cps/ml (IQR)
VL ≥50 cps/ml
VL ≥400 cps/ml
VL ≥1 000* cps/ml
Valid EID result
PCR positive
% IU transmission
per Unit
JHB B
2 103
1 230 (58.5%)
<40
(0–287)
415
(33.7%)
284
(23.1%)
254
(20.7%)
1 292
(61.4%) 19
(1.5%)
1.6
JHB D
3 324
693 (20.8%)
(0–387)
248
(35.8%)
169
(24.4%)
156
(22.5%)
1 305
(39.3%) 14
(1.1%)
1.5
JHB F
1 543
309 (20.0%)
(0–186)
102
(33.0%) 67
(21.7%) 58
(18.8%)
823
(53.3%) 7
(0.9%)
1.2
Tshwane Metro
1 177
537 (45.6%)
(0–2450)
242
(45.1%)
170
(31.7%)
153
(28.5%)
913
(77.6%) 25
(2.7%)
3.0
Total
8 147
2 769 (34.0%)
(0–398)
1 007 (36.4%)
690
(24.9%)
621
(22.4%)
4 333
(53.2%) 65
1.7

12. Discussion
≈20% of women delivering across the four obstetric units had a VL ≥1 000 cps/mL; 36% had a VL ≥50 cps/mL
eMTCT requires VL suppression throughout pregnancy, postpartum and during breastfeeding in HIV-positive women
Tshwane site had higher proportions of viraemic women at delivery compared to Johannesburg sites (p=0.001). A similar trend was observed for % neonatal positivity
Suggesting the Tshwane site had a higher MTCT-risk maternal population
% IU transmission rates ≈ programmatic IU transmission rates, overall and by site
Suggesting representativity of study population despite low coverage

13. Concluding Remarks
High maternal VL burden around time of delivery across multi-site tertiary obstetric units in Gauteng province, South Africa
Scale-up of VL monitoring and improving quality of ante- and postnatal care is urgently required for VL suppression around time of delivery and postpartum in breastfeeding populations for eMTCT