Improvements in prevention of mother-to-child transmission of HIV
(PMTCT) in South Africa are not translating into a reduction in maternal deaths due to
HIV infection, according to a 15-year review of a large district referral
hospital in Johannesburg, the 21st Conference on Retroviruses and Opportunistic
Infections (CROI) heard on Wednesday in Boston.
In particular, the audit found that there has been no change
in the proportion of maternal deaths caused by HIV since 2007, and over
three-quarters of women with HIV who died had never started antiretroviral
Prevention of HIV transmission from mother to infant is of
limited value for the child if the child’s mother dies in the early years of life.
Maternal mortality due to HIV infection has been shown to predict child
mortality. A study conducted in Uganda, published in 2003, found that children whose HIV-positive
mothers subsequently died had a 3.8-fold increase in the risk of death before
the age of six years. The risk of infant death after maternal mortality was
highest during the first year of life.
The South African review, presented by Coceka Mnyani of
University of Witwatersrand, looked at the records of Chris Hani Baragwanath
hospital, which serves an urban and periurban population of approximately 2
million people in Johannesburg. The hospital delivered between 17,000 and
23,500 babies a year between 1997 and 2012. HIV prevalence in the maternal
population served by the hospital is extremely high: approximately 23% of women
who give birth at the hospital were found to be HIV positive in 2012, compared
with 30.7% in 2004, the peak year for HIV prevalence among pregnant women
giving birth at the hospital.
The researchers identified 589 postpartum deaths in mothers
between 1997 and 2012. They found that 37% of deaths were non-pregnancy-related,
the single largest cause of death. The proportion of women who died who were HIV positive rose from 53.9% in 2003-8 to 65.8% in 2011-12, far in excess of the local HIV prevalence.
In women with HIV, the majority of deaths
were not pregnancy related (54% in 2011-12). Respiratory infections including tuberculosis (TB)
were the most common cause of death. Obstetric haemorrhage and
pregnancy-related sepsis were the most common causes of pregnancy-related
Although the proportion of women tested for HIV increased
from 74.9% in the 2003-8 period, to 83.6% in the 2011-12 period, this rate of testing
is still far below the level necessary for elimination of mother-to-child
transmission. Seventy per cent of mothers who died and who had been tested for HIV prior to delivery were
Although perinatal HIV transmission has declined from 6.9%
in 2007 to 1.5% in 2012, and the number of deaths among pregnant women has
declined, there has been little improvement in the proportion of women taking
antiretroviral therapy. While 7% of women who died in the period 2003-8 were on
antiretroviral therapy, this proportion rose to 28.3% in 2009-10, but fell
again to 22.9% in 2011-12. HIV-related deaths appear to have remained high
because of lack of engagement in care and lack of treatment. Three-quarters of
women who died had CD4 cell counts below 200 cells/mm3 – the median
CD4 cell count was 71 cells/mm3 – and 44% had defaulted from antiretroviral
“We’ve put an emphasis on PMTCT but we haven’t really put an
emphasis on saving the mothers,” said Coceka Mnyani.
Note: this article has been corrected to display the correct proportions of women tested for HIV.