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, updated May 2026 as version 2) and the National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024). The May 2026 version 2 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. Management rests on the practical cascade that follows, anchored in the core knowledge that makes each decision 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). The substitution ladder is worth holding: if tenofovir cannot be used, abacavir is the preferred alternative and the regimen becomes ABC + 3TC + DTG; only when TDF is unsuitable and the woman has had an abacavir hypersensitivity reaction does she receive AZT + 3TC + DTG, which is the whole of the remaining adult role for zidovudine. Where a protease inhibitor is still required, atazanavir/ritonavir replaces lopinavir/ritonavir as the preferred agent, except in a woman on TB treatment.
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 on a defined schedule, because incident (new) infection in pregnancy or lactation carries a very high transmission risk and is a recognised gap in the prevention cascade: at confirmation of pregnancy, at every full BANC visit, and at labour or immediately after delivery; then, for as long as she breastfeeds, at the 10-week EPI visit, at the 6-month integrated well-baby visit, and 3-monthly until six weeks after all breastfeeding has stopped. Ask her the date of her last test at every visit rather than assuming one was done. 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.