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, updated May 2026 as version 2) — which supersede the 2023 ART and 2019 PMTCT guidelines — and the SA HIV Clinicians Society Adult ART Guidelines. The May 2026 version 2 document is the current source of truth and the source of the specifics below; several of its changes land directly on what you say to a patient, so check that you are quoting the current edition before you counsel. 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 (PVT, the term that replaces "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 — the three-test strategy: South Africa now runs a three-test algorithm for everyone over 2 years of age, because national positivity has fallen below 5% and two tests no longer hold the positive predictive value above 99%. A reactive screening rapid test is followed by confirmatory rapid test 1, and if that is also reactive by confirmatory rapid test 2. HIV is reported positive only when all three are reactive. If confirmatory test 2 is non-reactive the result is discrepant and you request an HIV ELISA. If confirmatory test 1 is non-reactive, repeat the screening test only (do not re-run the whole algorithm): non-reactive on repeat means report negative; reactive on repeat means discrepant, so request an ELISA. An inconclusive ELISA returns in 14 days. Do not report a positive result off two tests, and do not send a Western blot — it is no longer part of the algorithm.
- Self-screening: HIV self-screening (HIVSS) is now an accepted entry point for adolescents and adults over 12 years, and its use has been expanded to PEP follow-up, PrEP continuation from the second follow-up visit, PrEP re-engagement (with the confirmatory test done at a facility), triage within facility-based testing, and index and social-network testing. A reactive self-screen is not a diagnosis — it enters the three-test algorithm above.
- Window period: HIV antibody tests detect ~3 weeks post-exposure; 4th-generation antigen/antibody combination tests ~2 weeks; PCR ~10 days. Routine retesting to cover the window period has been dropped. It is now indicated in only three circumstances: after sexual violence (retest at 6 and 12 weeks), after occupational exposure or where PEP has been issued (6 and 12 weeks), and where the patient has signs or symptoms of acute HIV seroconversion (6 weeks). This is a change registrars get wrong: a negative test in a patient with no recent exposure does not need a routine three-month repeat.
- Post-test counselling:
- Negative: reinforce prevention, condom use, PrEP if at substantial risk, and set the next routine test date; add a window-period repeat only if she falls into one of the three circumstances above.
- Positive: report positive only once the full three-test algorithm is complete, then link to care the same day where possible, baseline staging (CD4 with reflex cryptococcal antigen if ≤ 200, viral load, TB screening, syphilis, hepatitis B/C, pregnancy test), and 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).
The substitution ladder changed in 2026 and is worth holding, because the old efavirenz answer is now wrong. If tenofovir cannot be used, abacavir is the preferred alternative and the regimen becomes ABC + 3TC + DTG. Zidovudine is no longer part of any standard adult regimen; it is reserved for the patient who has both renal failure and abacavir hypersensitivity, and for preterm neonates. Where a protease inhibitor is still required, atazanavir/ritonavir replaces lopinavir/ritonavir as the preferred agent, except in a woman on TB treatment. Switching a woman from the old TEE regimen (TDF + emtricitabine + efavirenz) to TLD is now simplified and does not wait for a viral load.