HIV related infections remain the leading cause of maternal deaths in South Africa despite the availability of ART
Polly Clayden, HIV i-Base
HIV remains the leading cause of maternal death in South Africa despite a steep decline in vertical transmission, according to data presented at CROI 2014.
Researchers from University of the Witwatersrand and Anova Health Institute conducted a review of maternal deaths at Chris Hani Baragwanath hospital. The hospital is an academic tertiary centre and a district referral facility serving a population of approximately two million people from a mixture of urban and informal settlements in Johannesburg. Coceka Mnyani presented the data on behalf of the group.
The study was conducted between 1997 and 2012 during which time the number of deliveries at the hospital increased from approximately 16,000 a year to over 20,000 – where the rate currently stands. The prevalence of HIV was very high in the mothers giving birth, reaching a peak of 30.7% in 2004 compared to 23.6% in 2012. In 2012 the rate of vertical transmission was 1.5%, compared to 6.9% in 2007.
The researchers considered time trends in their analysis coinciding with PMTCT and ART guideline changes in South Africa (see Table 1).
Table 1. Changes in PMTCT/ART availability in South Africa 1997 to 2012
|1997-2002||No PMTCT interventions|
|2003-2008||sdNVP for PMTCTART from 2003, CD4 threshold 200 cell/mm3|
|2009-2010||AZT for PMTCT
From 2010, ART CD4 threshold 350 cells/mm3
|2011-2012||ART availability within antenatal clinics|
There were 589 maternal deaths during the 15-year period. The researchers found that the leading cause of death throughout the four time periods was from non-pregnancy related infections reported in over a third of the mothers who died. The next biggest causes of maternal death were hypertensive disorders and obstetric haemorrhage.
Of the women in the study tested for HIV, 70.7% (285/403) were HIV positive. The HIV testing rate of pregnant women increased over time from less than 50% in 1997 to 2002 to over 80% in 2011 to 2012. The proportion of mothers with HIV that died also increased during the study period: 31% in 1997 to 2002, 53.9% in 2003 to 2008, 53.5% in 2009 to 2010 and 65.8% in 2011 to 2012.
There were 285 deaths among the HIV positive women with a mean age of 29.3 years at time of death. The median CD4 count of the women was very low with 74.6% less than 200 cells/mm3 and only 9% greater than 350 cells/mm3.
Despite the availability of ART, the number of women receiving it remained very low: 10%, 13% and 11% during 2003 to 2008, 2009 to 2010 and 2011 to 2012 respectively. For the few women who were started on ART for their own health (n=13) the median duration of treatment was quite long at 56 weeks but 44.4% had defaulted at the time of death. The median duration of ART was four weeks for those who started in pregnancy.
The majority (80.7%) of deaths among HIV positive women occurred post partum with 78.8% in the first week. Non-pregnancy related infections remained the leading cause of death – responsible for 62% of deaths in HIV positive women. The majority of infections were respiratory particularly community acquired pneumonia and pulmonary TB. Obstetric haemorrhage, pregnancy related sepsis, medical and surgical disorders and hypertensive disorders caused 9.1%, 6.7%, 5.3% and 4.6% of deaths in HIV positive women who died.
Dr Mnyani concluded that HIV related infections remain the leading cause of maternal deaths in South Africa despite the availability of ART. Contributing factors include women presenting late and defaulting treatment, and starting ART is often delayed.
The study has been extended to December 2014 to assess the impact of the extended ART programme and the recent availability of efavirenz-based fixed dose combinations for all HIV positive women.
Depressing news – these findings are similar to those reported before the widespread availability of ART. In South Africa, gains in prevention of childhood HIV are not reflected in maternal mortality rates.
Targeted interventions to decrease the high rate of HIV-related maternal deaths are urgently needed.
Mnyani CN et al. A 15-Year Review of Maternal Deaths in a Background of Changing HIV Management Guidelines. 21st CROI. 3-6 March 2014, Boston. Oral abstract 67.