The 26th Conference on Priorities in Perinatal Care in South Africa was held under the auspices of the Priorities in Perinatal Care Association and sponsored by Abbott Laboratories sa (Pty) Ltd

Counselling for HIV testing is provided for pregnant women whose HIV status is unknown during labour

Sufficiency of evidence: C Strength of recommendation for implementation: 1

• 
  Inform all women with unknown HIV status who visit the hospital for the birth of their babies about PMTCT and inform them that they can still be tested for HIV during labour.
  
• 
  Use a rapid test if the woman gives her consent to be tested and administer Nevirapine to the mother and baby if she is found to be HIV positive.
  
• 
  Provide the opportunity to be counselled and tested after the delivery when a woman with an unknown HIV status is admitted in advanced labour and is not susceptible to counselling.
  
• 
  Offer couple counselling and testing if the woman’s partner has accompanied her to hospital.
  

POSTER 13
Perinatal mother to child transmission of HIV – an audit of the Tygerberg Hospital program.
AM Theron and GB Theron

Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital.

Introduction

In 2006 globally there were 530,000 new HIV infections in children and 380, 000 AIDS deaths amongst children. Of the 2.8 million children infected with HIV (2005), 80% live in sub-Saharan Africa. The vast majority of infections are acquired through mother to child transmission. The mainstay of the provincial perinatal mother to child transmission (PMTCT) programme is the use of anti-retrovirals (ARV’s) to reduce vertical transmission. The provincial Department of Health requires careful audit of the PMTCT program in hospitals and clinics. Records are kept on specially designed data sheets in the antenatal clinics, labour wards, postnatal and neonatal wards. A compilation of routine data allows the success of the program to be measured. The two tertiary hospitals in the Cape Metropole are the two worst performers.

Methods

Routinely collected data at Tygerberg Hospital (TBH) from January to June 2007 (Table I) were evaluated to determine the reasons for the poor performance. Adequate intervention with ARV’s are regarded as zudovidine (AZT) at least for 2 weeks during the antenatal period, single dose nevirapine (NVP) and AZT 3 hourly during labour and NVP and AZT syrup administered to the neonates. The reasons for not achieving optimal ARV administration to prevent PMTCT of HIV were also assessed.

Results

A total of 469 HIV positive women were delivered during the first 6 months of 2007. Of these, 117 (24.9%) were referred from other hospitals and midwife obstetrics units. During these 6 months 51 (10.9%) of HIV positive women were on HAART and a further 31 (8.0%) had CD4 counts less than 200 cells/ml, but were not on HAART (Table II). A total 293 (62.5%) women received AZT at least for 2 weeks during the antenatal period, 294 (62.7%) received NVP during labour and 258 (52.0%) AZT 3 hourly during labour (Table III). Reasons why ARV’s were not administered and adjusted percentages taking avoidable factors out of control of the health workers in account are given in Table IV. Patient and medical care related avoidable factors were responsible for 51.7% and 28.9% of treatment failures respectively. There were 447 live born babies of whom 463 (97.5%) received AZT and 469 (98.7%) NVP.

Discussion

Reasons for the apparent poor performance were investigated and the adjusted figures present the success of the PMTCT programme at TBH. Steps were taken in the department to address the medical care related avoidable factors during the antenatal and postpartum periods. The administration of ARV’s to the newborn babies achieved an exceptionally high success rate..

Table I An audit of deliveries at TBH from January to June 2007

NVD	2445
C/S	1050 (27.5%)
Breech	66
Vac ext	60
Forceps	5
BBA	194 (HIV + 14.4%)
Total	3820
HIV +	469 (12.3%)

Table II The proportion of women with low CD4 counts

Total 469

On HAART 51 (10.9%)

CD4 <200 26

CD4 >200 25

Not on HAART

CD4 known 387 unknown 31

<200 31 (8.0%)

>200 356

CD4 <200 and HAART CD4 <200

31 + 51 = 82 (18.7%)

Table III Successful ARV intervention to prevent PMTCT of HIV

HIV +	469 (%)
Referred cases (also MOU’s)	117 (24.9)
Antenatal AZT > 2 weeks	293 (62.5)
AZT during labour	258 (52.0)
sd NVP during labour	294 (62.7)
Adequate dual therapy	186 (44.5)
HAART	51 (10.9)
C/S rate	158 (33.5)

Table IV Avoidable factors related to ARV intervention

Reasons for failure

BBA 28 (unbooked 13)

IUD 15

Unbooked 33

Fully dilated 44 (unbooked 4)

Adjusted %

Antenatal AZT > 2 weeks

> 2 weeks 62.5  73.1%

Adequate

dual therapy 44.5  73.4%

Patient related avoidable factors 120 (51.7%)

Unbooked & late bookers

Admitted fully dilated

BBA

Medical care related avoidable factors 67 (28.9%)

Not prescribed (doctors) 15

Not given (nurses) 52

Other 45 (19.4%)

severely ill, anaemia, referred (27)

POSTER 14
CAESAREAN SECTION IN THE IMMUNOCOMPROMISED PATIENT WITH AIDS: A GUIDELINE
NF Moran

Department of Obstetrics and Gynaecology, Mahatma Gandhi Memorial Hospital, and Nelson R. Mandela School of Medicine, UKZN

Introduction

In KZN, antenatal HIV prevalence is now 40%. Of these HIV positive pregnant women approximately 10-20% have AIDS, as defined by a CD4 count of less than 200 or a history of an AIDS-defining illness. Many of these women reach term without having started HAART, or having only recently started HAART, and thus remain severely immunocompromised by the time they deliver their babies. It is therefore now a common occurrence in KZN for a doctor to have to perform a caesarean section on an immunocompromised woman with AIDS.

There is very little data available about the outcome of caesarean section in this category of patient. However, there are special concerns that relate to performing a caesarean on such patients. These include the following:

1. 
   there is a risk of subclinical intrauterine infection being present at the time the caesarean section is performed, increasing the risk of puerperal and neonatal sepsis
   
2. 
   normal healing processes following the caesarean are likely to be impaired, leading to a high risk of puerperal sepsis
   
3. 
   there is a high risk of vertical transmission of HIV to the baby during the procedure, due to the high viral load
   
4. 
   for the same reason, there is a high risk of the health worker contracting HIV should occupational injury occur during the procedure
   

If special attention is paid to these concerns, during the pre-operative preparation, the intra-operative procedure and the immediate post-natal period, it is likely that the outcome of caesarean section in the AIDS patient would be improved.
Method

A proposed guideline for doctors on how to perform caesarean section in the immunocompromised patient with AIDS has been written. The guideline puts emphasis on modifications of conventional procedure or technique which are likely to have benefits specifically in the context of the AIDS patient. Due to a lack of studies evaluating different methods of caesarean section in the AIDS patient, the guideline is based mainly on theory and common sense.

The Guideline

Caesarean Section in the Immunocompromised Patient with AIDS:

A Guideline
Purpose of Guideline

To minimise adverse outcomes resulting from caesarean section (C/S) in the patient with AIDS

Need for a Guideline

It is now a common occurrence in KZN to have to perform a C/S in a patient with AIDS (HIV +ve and CD4 < 200 or AIDS-defining illness). These patients are immunocompromised and often have a high viral load, which means that C/S carries a high risk of adverse outcomes including:

• 
  Puerperal sepsis
  
• 
  Vertical transmission of HIV at delivery
  
• 
  Transmission of HIV to health worker if occupational injury occurs at C/S
  

This guideline offers suggestions for preventing these adverse outcomes when performing a C/S in the AIDS patient.
Pre-operative Measures

• 
  Ensure that the CD4 result is obtained prior to any C/S for an HIV +ve patient, so that patients with AIDS can be identified and the following measures implemented.
  
• 
  In maternal interest, try to avoid C/S in the AIDS patient unless strongly indicated. For example, allow vaginal birth after previous C/S x1, and consider ECV or vaginal breech delivery rather than C/S for breech presentation
  
• 
  Start HAART before C/S, so as to bring down the viral load before delivery. Even starting HAART a few days before delivery should be effective. There is no upper limit to the gestation at which HAART can be started. If necessary postpone an elective C/S to allow time for HAART to be started. Do not omit HAART on the day of the C/S.
  
• 
  Start therapeutic intravenous broad-spectrum antibiotics (e.g. Co-amoxyclav) as part of the pre-op prep, before the patient is sent to the theatre.
  

Intra-operative Measures

• 
  The operation should be performed by an experienced surgeon who must not rush the surgery.
  
• 
  Full protective clothing (double gloves, eye protection, aprons etc) must be worn by surgeon, assistants and scrub sister.
  
• 
  The skin incision should be either midline or Joel-Cohen (high transverse) to allow good exposure with minimal dissection. Avoid going through a Pfannenstiel (low transverse) scar from a previous C/S, as this often requires extensive dissection.
  
• 
  Enter the uterus with extreme care, preferably by blunt entry, to avoid any laceration to the baby.
  
• 
  Avoid forceps delivery of the baby’s head, unless essential to achieve delivery of a high head.
  
• 
  Avoid suctioning of the baby at birth unless required for resuscitation
  
• 
  Have a warm wet swab at hand to wipe maternal blood from the face and body of the baby immediately at birth
  
• 
  If the baby sustains a laceration at delivery, clean it immediately with hibitane and dress it to prevent further contamination.
  
• 
  Consider the use of blunt needles for suturing the uterus, and for tubal ligation where applicable, to reduce needlestick injuries.
  
• 
  Perform a thorough washout of the pelvis following closure of the uterus.
  
• 
  Close the skin and subcutaneous tissue together with a few interrupted deep mattress sutures. Avoid subcuticular or staple closure of the skin, leaving the subcutaneous layer unsutured, as this predisposes to wound haematoma and subsequent sepsis.
  

Post-operative Measures

• 
  Ensure baby receives prophylactic ARVs according to local protocol, and institute appropriate feeding method as decided antenatally.
  
• 
  In cases where the baby has sustained a laceration during the caesarean, the baby should receive more intensive post-exposure ARV prophylaxis, ideally triple ARV therapy for a month.
  
• 
  Continue the therapeutic broad-spectrum antibiotics for 3 days post-op.
  
• 
  Continue HAART daily for life.
  
• 
  Keep the mother as an in-patient for 5 to 7 days until skin sutures are removed, to allow close monitoring for early signs of puerperal sepsis
  

Conclusion

Ideally, pregnant women with AIDS should be started on HAART long before they are due to deliver, so that they have a low viral load, and are no longer severely immunocompromised, by the time they deliver. However, in practice, this often does not occur. It is hoped that the dissemination of this guideline may improve the outcome of caesarean section in those women who remain severely immunocompromised at the time of delivery.

Further Research

The guideline will be displayed and distributed to doctors and midwives in the Department of Obstetrics at Mahatma Gandhi Memorial Hospital. An audit of the outcome of caesarean section in the AIDS patient is planned. Important outcome measures will include the incidence of puerperal sepsis, and the peri-operative vertical transmission rate of HIV as measured by the 6-week PCR.

POSTER 15
THE ROLE OF PREGNANCY INTENTION IN HIV PREVENTION IN SOUTH AFRICA
Hazel Rashe¹, Marjorie R. Sable², M. Kay Libbus³, Debra Jackson¹, and Harry Hausler<sup>1

1</sup>School of Public Health, University of the Western Cape, Cape Town, South Africa; ²School of Social Work and ³School of Nursing, University of Missouri, USA
Introduction

Perinatal transmission of HIV from mother to child during pregnancy, birth, and breastfeeding is one of the driving forces of the AIDS epidemic in South Africa. The antenatal seroprevalence among women in South Africa rose from less than 1% in 1990 to 29.1% in 2006, varying by region. In rural KwaZulu-Natal, where our research was conducted, the estimated antenatal prevalence rate of HIV was 39.1%. It is particularly important to understand pregnancy intention among women and men who are HIV positive to prevent perinatal transmission. Many people infected with HIV continue to be sexually active and, as a result, are faced with decisions regarding reproductive intention and behavior.

Methods

• 
  Six focus groups were conducted among women and men in rural KwaZulu Natal Province.
  
• 
  Theory of Planned Behavior (TPB) theoretical construct (Ajzen, 1985) used to elicit:
  
  • 
    attitudes about becoming pregnant and having children
    
  • 
    specific social referents who are perceived to influence the pregnancy decisions and childbearing
    
  • 
    control beliefs about becoming pregnant.
    
• 
  Total sample size: 35 women and 16 men
  
  • 
    Community women (3 groups)
    
  • 
    Community men (1 group)
    
  • 
    Female ARV clinic patients (1 group)
    
  • 
    Male ARV clinic patients (1 group)
    

Results

We identified social, health and other factors central to all three of the TPB’s theoretical constructs, including.

• 
  widespread poverty
  
• 
  gender violence
  
• 
  religious beliefs and cultural taboos
  
• 
  social stigma attached to the diagnosis of HIV
  

Table 1. Demographics of Focus Group Participants
	Females (n=35)	Males (n=16)
Mean age	32.6 (range 21-57)	38.1 (range 28-53)
Married	34%	0%
Mean # of pregnancies	3.2 (range 0-10)	n.a.
Mean # of children	2.7 (range 0-8)	1.9 (range 1-4)
Living with:
Spouse/partner	26%	76%
Children	77%	8%
Parents	23%	23%
In-laws	17%	8%

Themes emerging from the focus groups

ATTITUDES ABOUT HAVING CHILDREN

• 
  Leaving a legacy
  

“Some people who are HIV positive have a lot of assets. This makes them pressured to have a child, just to leave a legacy behind.”
SOCIAL INFLUENCES AROUND CHILDBEARING:

• 
  The role of the Makoti system and influence of the mother-in-law
  

“…Yes, some people do influence you, especially if you are a married woman because the in-laws will want you to produce.”

 “This is not in your control at all if you are married. The in-laws say that you have come to produce here.”

“Sometimes women have no control over having pregnancy because they have to impress their in-laws (whole family, including partner).”

“Dowry has been paid so they are expected to produce.”

STIGMA

“If you remove the stigma of being HIV+, some still think that you can never be pregnant if you are positive.”

 “Yes, we are scared very much. I remember when I started to be sick. The nurses were very hateful and rude. They called us names; I hate those nurses.”

“Some families … separate the child from others if you are HIV+.”

 

PERCEIVED CONTROL OVER HAVING CHILDREN

 “It won’t be easy to say I don’t want to fall pregnant.”

 “I can just say no, I don’t want to get pregnant because I love to be loved; your husband forgets about you and just loves the kids more.”

 

CONDOM USAGE

“Men will complain and say, ‘What have you been doing? Have you been sleeping around?’ And they will fight” it.

“Some men believe … condoms come with HIV because of oiliness.”

“The white people put the oily medicine on them to infect us.”

 

INFLUENCE OF HIV/AIDS ON REPRODUCTIVE DECISIONS

“No falling pregnant for HIV+ woman. There are too many funerals because this baby will also die.”

“They (mothers-in-law) won’t like your baby; they won’t even play with your baby. They think that if your baby urinates on them, the urine will go straight to the vagina and they will get HIV.”

“I just think of death because this sickness that we have is leaving us with small babies left behind.”
Conclusion

Mother-to-child transmission represents a continuing source of new HIV infection in South Africa. Understanding the sociocultural, economic and environmental milieu in which both pregnancy and HIV transmission occur is vital to developing interventions that will make societal change and reverse the trend of the growing HIV epidemic.

POSTER 16
WOMEN'S EXPERIENCE OF PARTICIPATING IN AN HIV SUPPORT GROUP - A QUALITATIVE ASSESSMENT
Jonathan Mundell (Serithi Project); Maretha Visser (University of Pretoria)
Introduction

Support groups are generally regarded as an effective way of assisting people who are living with HIV/AIDS to cope with their situation. There are however, very few studies that have attempted to explore the actual experiences and perceived benefits from participation in HIV-related support groups.

Methods

In this study, the experiences of women participating in HIV supports groups in Tshwane (Pretoria) were explored. Recently diagnosed HIV+ pregnant women were recruited from four VCT clinics in Tshwane (Pretoria) through the Serithi project and invited to take part in the support group programme. Over a period of two years, 140 women participated in support groups. The support group program consisted of ten structured sessions, addressing various HIV-relevant topics, specifically developed to meet the needs of the women. Individual interviews were conducted with all participants at the end of the support groups and again after 6 months. Three focus group discussions were conducted with 20 women at a one-year follow-up. The data from these interviews and focus group discussions was transcribed, and then coded and analysed using QSR N6 software.