HIV in Pregnancy: Preventing Mother-to-Child Transmission

This article is educational content based on current peer-reviewed guidelines, including the SA National Department of Health PMTCT Guideline (2019, with Feb 2020 updates), the DHHS 2025 Perinatal Guidelines, the SAHCS 2025 PrEP Guideline, and the Dugdale 2025 Lancet meta-analysis. It is not personalised medical advice. Every pregnancy is different. Please seek individual clinical care from a qualified healthcare provider.

Planning a pregnancy or newly pregnant with HIV? Book a consultation at NeoHealth.

Why HIV in pregnancy is different from HIV in general

Pregnancy with HIV is two clinical situations at once: the woman's own health, and the baby she is carrying. The goals overlap but the priorities shift. Preventing transmission to the infant joins maintaining maternal suppression as co-equal aims.

In South Africa, the medical picture for HIV in pregnancy has transformed. Mother-to-child transmission rates have fallen from over 30% in the pre-ART era to under 2% with current antenatal care. This is one of the most important public health wins in SA medicine. It depends on women testing, starting or continuing ART, and maintaining adherence through the nine months and after.

Pregnancy changes the clinical picture in three specific ways:

First, the stakes include a second person. HIV can transmit to the baby during pregnancy, at delivery, and through breastfeeding. Without intervention, the cumulative risk is roughly 40%. With modern ART and the SA PMTCT programme, that number can be reduced to effectively zero.

Second, some medications and combinations that work for adults require pregnancy-specific consideration. Not every antiretroviral is suitable at every gestational stage. Not every contraceptive interaction matters outside pregnancy but matters during. Dolutegravir has a small but real preconception risk question (detailed below). These need individual conversation.

Third, the postnatal period is where things often fall apart. Viral suppression that was hard-won in pregnancy can slip in the sleep-deprived, overwhelmed first year with a new baby. South African data show that most remaining mother-to-child transmissions now happen through breastfeeding, not at delivery, because maternal adherence drops after birth. The PMTCT programme has shifted its focus accordingly.

The rest of this article walks through each of these in the order a pregnancy unfolds.

The three routes of mother-to-child transmission

Transmission can occur through three distinct biological routes, and each requires its own prevention strategy:

In utero (during pregnancy). The virus can cross the placenta, particularly in the third trimester if the mother's viral load is uncontrolled. Without ART, this accounts for roughly 5% of all MTCT.

Intrapartum (at delivery). The largest risk window historically. As the baby passes through the birth canal, exposure to maternal blood and cervicovaginal fluids carries transmission risk if viral load is detectable. Without ART, this accounts for 15 to 20% of MTCT.

Postpartum through breastfeeding. Small amounts of virus can be present in breast milk. With uncontrolled HIV and mixed feeding, this accounts for 20% of MTCT over 24 months of breastfeeding. With sustained ART suppression, the risk is very low but not zero.

Modern PMTCT interventions target all three routes: ART to suppress the virus during pregnancy and beyond, safe delivery techniques where needed, infant prophylaxis to cover residual delivery-period exposure, and continued ART plus infant prophylaxis during breastfeeding.

Before pregnancy: preconception planning

If you or your partner has HIV and you are planning a pregnancy, the best approach is to plan. Conception does not need to be left to chance, and if one partner has HIV, the other does not need to be put at risk. Talk to us before trying to conceive. The preconception visit takes 30 minutes, and it saves months of uncertainty.

The single most effective MTCT prevention is being virally suppressed before you conceive. A 2025 Lancet systematic review of approximately 80,000 mother-child pairs found zero perinatal transmissions among women who started ART before pregnancy and maintained viral load under 50 copies per mL throughout. This is the strongest evidence we have that preconception ART, sustained, effectively eliminates in-utero and intrapartum transmission.

For women already living with HIV who are planning a pregnancy:

1. Aim for sustained viral suppression for at least 6 months before trying to conceive.
2. Review your current regimen with your clinician. Is it pregnancy-compatible?
3. Start folic acid supplementation (500 micrograms to 1 mg daily) at least a month before conception. For women on dolutegravir-based regimens, some guidance recommends higher-dose folate (5 mg daily) for the periconception period, though evidence is evolving.
4. Screen for and treat any STIs. Untreated STIs in pregnancy are associated with preterm labour and increase the risk of HIV transmission to the baby if the mother is not fully suppressed.
5. Check hepatitis B status. Tenofovir (the T in TLD) also treats hepatitis B.
6. Optimise general health: blood pressure, weight, nutrition, mental health, any chronic conditions.
7. If your partner is HIV-negative, discuss whether PrEP during the conception period adds reassurance. It is not required if you are sustainably suppressed, but some couples choose it.

For HIV-negative women planning a pregnancy with an HIV-positive partner:

If the partner is virally suppressed, natural conception through timed intercourse is safe. Multiple large prospective studies (HPTN 052, PARTNER, Opposites Attract) have documented zero HIV transmissions in hundreds of thousands of condomless sex acts when the partner with HIV was virally suppressed. See our long-term HIV management article for the full U=U evidence base.

If the partner's viral load is not yet suppressed, or suppression is recent, PrEP is strongly recommended for the woman attempting conception. The SAHCS 2025 PrEP Guideline explicitly supports oral TDF/FTC PrEP through conception, pregnancy, and breastfeeding. See our PrEP article for detail.

First antenatal visit: HIV testing for everyone

In South Africa, every pregnant woman is offered an HIV test at the first antenatal visit. This is core public health practice and is not optional in the sense that it would be unusual to decline, though of course any person may choose to decline any test.

The reasons this matters:

• Roughly one in four pregnant women in South Africa is living with HIV. National antenatal HIV prevalence in 2022 was 27.5%, with provincial variation from around 15% (Western Cape, Northern Cape) up to 37% (KwaZulu-Natal). A 2026 Free State study (Khaliq et al.) found 27.9% HIV prevalence in primary-care antenatal attendees, with 22.4% of those women being newly diagnosed at the booking visit.
• The earlier ART starts, the lower the transmission risk. For every week of suppressive ART during pregnancy, the MTCT risk is reduced by about 10%.
• Repeat testing matters. HIV-negative women should be retested at every subsequent antenatal visit and during breastfeeding. Acute HIV acquisition during pregnancy carries a particularly high transmission risk to the baby because viral loads spike in primary infection.

At NeoHealth, HIV testing at the first antenatal visit is part of the standard booking bloods. Result turnaround is rapid. Confidentiality is protected through routine consultation coding without any separate "HIV clinic" label.

If you are newly diagnosed with HIV during pregnancy

A new HIV diagnosis during pregnancy is a hard moment. You are already carrying the mental load of pregnancy. The diagnosis adds questions about your own health, your baby's health, and potentially your partner's status. It is normal to feel fear, anger, grief, or numbness in the first days.

Here is what is true:

• Your baby does not have HIV yet unless transmission has already occurred, which is uncommon in early pregnancy.
• Starting ART now, in pregnancy, reduces the risk of transmission to your baby to under 1% when adherence is good and viral load becomes undetectable before delivery.
• You have time to absorb this. Not unlimited time, but enough to start treatment properly, ask questions, and decide how to tell the people you need to tell.

At NeoHealth, a new-diagnosis visit takes as long as it takes. We will initiate ART, arrange confirmatory tests and baseline bloods, discuss who in your life needs to know and when, and set up the monitoring schedule for the rest of your pregnancy. The overwhelming priority is to get ART started as soon as possible, because every week of suppressive ART in pregnancy reduces transmission risk.

What typically happens:

1. The HIV test is positive. The SA algorithm requires a confirmatory rapid test, then a lab-based confirmation. Your clinician discusses the result.
2. Baseline bloods are done: CD4 count, creatinine (kidney function), viral load, TB screen, syphilis, hepatitis B.
3. ART is started the same day or within days, unless there is a specific contra-indication like active tuberculosis requiring treatment first.
4. Appropriate counselling covers the regimen, side effects, adherence, partner testing, and U=U concepts.
5. A community-based support referral is made if available, including linkage to a mentor mother programme, MomConnect, or peer support group.

The 2019 SA PMTCT guideline moved strongly toward same-day ART initiation at the first antenatal booking, because delays of even weeks meaningfully increase transmission risk.

The regimen for a newly diagnosed pregnant woman in current SA guidance is:

• TLD (tenofovir + lamivudine + dolutegravir in a single fixed-dose tablet, once daily) for women from 7 weeks of gestation onwards.
• TEE (tenofovir + emtricitabine + efavirenz) for women diagnosed in the first 6 weeks of pregnancy, or with a specific reason to avoid dolutegravir (see the DTG section below).

The choice between TLD and TEE is discussed with the woman, who makes an informed decision.

If you are already on ART when pregnant

For women already on ART who become pregnant, the first step is to confirm that the current regimen is pregnancy-compatible and that viral load is suppressed.

Scenarios:

• Already on TLD with sustained suppression: Continue TLD. This is the preferred regimen in pregnancy.
• Already on TEE (efavirenz-based): Can continue. Can also consider switching to TLD once past the first 6 weeks of pregnancy, provided viral load is suppressed in the last 6 months, with appropriate counselling.
• Already on a boosted protease inhibitor regimen: Usually continued. May be switched to a newer regimen depending on circumstances.
• Known HIV-positive but not currently on ART (previous default, or previously on PMTCT only): This is managed as a priority. If there is a documented previously suppressed viral load on ART, TLD is restarted. If viral load was not previously suppressed, AZT + 3TC + DTG is typically used because of the higher likelihood of concomitant resistance to TDF and EFV from previous exposure.

In all cases, viral load is checked at the first antenatal visit and again at 3 months if ART has been newly started or modified.

Which ART regimen in pregnancy

The two main options in 2026 SA practice are TLD and TEE.

TLD (tenofovir + lamivudine + dolutegravir) is preferred for most pregnant women. Advantages:

• Highly effective, with faster viral suppression than older regimens (most women reach undetectable within 8 to 12 weeks).
• High barrier to drug resistance.
• Well tolerated, with few drug interactions.
• Single tablet once daily.
• Safe from the seventh week of pregnancy onwards.
• Continues seamlessly postpartum for lifelong ART.

TEE (tenofovir + emtricitabine + efavirenz) is the main alternative. Historically the SA first-line regimen before 2019. Advantages:

• Long track record of safety throughout pregnancy, including the first 6 weeks.
• No neural tube defect signal.
• Single tablet once daily.

Efavirenz can cause vivid dreams, insomnia, or mood changes in some women, particularly in the first weeks. These usually settle.

In the private sector, bictegravir-based single-tablet regimens (B/F/TAF) are also available, and international guidance now positions them differently to SA guidance. The US DHHS 2025 Perinatal Guidelines list bictegravir/TAF/FTC as a preferred regimen in pregnancy for women already established and suppressed on it, and as an alternative for newly initiating women. The SA NDoH PMTCT guideline remains TLD-first for public-sector use, largely because TLD is the SA national fixed-dose combination and the SA evidence base is built on it. In private practice, where both regimens are accessible, the choice is individualised. If you are established on B/F/TAF and virally suppressed when pregnancy is confirmed, there is no need to switch.

The DTG and neural tube defect question

Dolutegravir (DTG) is the preferred ART anchor drug globally and in South Africa. This section addresses the neural-tube-defect concern that briefly changed that recommendation, and where current evidence stands.

The background. In 2018, an early analysis from the Tsepamo surveillance study in Botswana identified a small signal suggesting that dolutegravir at the time of conception might increase the risk of neural tube defects (NTDs, the most well-known being spina bifida). The neural tube closes by the end of the sixth week of pregnancy, so the window of concern is preconception through the first 6 weeks. See Zash et al., NEJM 2019 for the Tsepamo data. This was initially concerning, and for a short period DTG was not recommended for women planning pregnancy.

The current evidence. With much larger data now available, the risk difference is:

• Background NTD risk on alternative regimens like efavirenz: approximately 0.1% (1 in 1,000).
• NTD risk with dolutegravir at the time of conception: approximately 0.3% (3 in 1,000).
• An absolute risk difference of roughly 2 additional NTDs per 1,000 periconception DTG exposures.

What this means practically. The absolute risk is very small. Dolutegravir is highly effective, well tolerated, and strongly recommended for most women with HIV. The World Health Organisation now recommends DTG as first-line for all adults, including women planning pregnancy, provided they have been informed of the NTD risk.

South Africa has taken a slightly more conservative approach. DTG is avoided in the first 6 weeks of pregnancy (from the last menstrual period through week 6). From week 7 onwards, DTG is the preferred ART.

For women planning pregnancy who are on DTG: current SA guidance is that they should be informed of the NTD risk and choose either to continue DTG (with folate supplementation) or switch to TEE. Either is a reasonable choice. Increasingly, even this restriction is being reconsidered internationally as the evidence base grows.

For women who become pregnant while on DTG and are past 6 weeks: no change needed. DTG is continued.

This entire conversation is one that Dr Chellan discusses in detail at preconception and early antenatal visits.

Viral load monitoring during pregnancy

Viral load (VL) is the primary metric of PMTCT success. The SA schedule in the 2019 guideline:

If newly starting ART in pregnancy:

• First VL at 3 months on ART.
• If suppressed (<50 copies per mL), repeat VL at delivery.
• If not suppressed, work through the viral load non-suppression algorithm (adherence, drug interactions, resistance, regimen change if indicated).

If already on ART at pregnancy diagnosis:

• VL at the first antenatal visit.
• If suppressed, repeat VL at delivery.

At delivery: VL for every woman with HIV. This is the key marker for infant risk classification.

After delivery:

• VL at 6 months postpartum, regardless of feeding choice.
• Every 6 months during breastfeeding.
• Continues as part of routine lifelong ART monitoring afterwards.

If viral load is detectable at any point (>50 copies per mL): this triggers urgent review. The cause is investigated: adherence, drug interactions, intercurrent illness, resistance. Adjustments are made. Infant prophylaxis is extended or intensified if the mother is breastfeeding.

An elevated viral load in pregnancy or breastfeeding is treated as a clinical priority, not a routine follow-up item. Same-week review is standard.

At delivery: what happens

NeoHealth does not perform deliveries. Antenatal care and HIV management during pregnancy are provided at the practice; delivery is referred to a specialist obstetrician at Mediclinic George or the woman's preferred private hospital. For public-sector patients, the referral route is through George Hospital.

That said, it is useful to understand what happens at delivery for a woman with HIV:

• Mode of delivery: Vaginal delivery is safe when viral load is well controlled (<1,000 copies per mL, ideally <50). Caesarean section is reserved for obstetric indications, or is considered when viral load is elevated close to delivery.
• Intrapartum ART: The woman's usual ART continues at usual dosing times during labour.
• For women diagnosed only at labour (rare but it happens): a stat dose of nevirapine plus a stat dose of TLD is given, and lifelong ART is initiated the following day.
• Delivery viral load: Every woman has a VL drawn at delivery. Results guide infant prophylaxis decisions.
• Labour-ward techniques: Episiotomy and assisted delivery are avoided where possible. Prolonged rupture of membranes is avoided. Unnecessary suctioning of the infant is avoided.
• Immediately after birth: Skin-to-skin contact with the mother is encouraged. Breastfeeding is initiated within the first hour if the mother has chosen to breastfeed.

The obstetrician and the hospital's paediatric team manage the intrapartum and immediate postnatal period. Dr Chellan takes over the mother's ongoing HIV care at discharge and sees the mother and baby together for the postnatal reviews.

Infant prophylaxis: what the baby receives

Every baby born to a mother with HIV receives preventive antiretroviral drops. The regimen depends on risk classification.

Low-risk infant (mother's VL under 1,000 copies per mL in the last 12 weeks of pregnancy or at delivery):

• Nevirapine (NVP) once daily for 6 weeks, whether breastfed or formula fed.

High-risk infant at birth (mother's VL 1,000 copies per mL or higher at delivery or in the last 12 weeks, OR no VL result available in the last 12 weeks, OR mother's HIV status unknown):

• Nevirapine once daily for a minimum of 12 weeks, AND
• Zidovudine (AZT) twice daily for 6 weeks.
• Nevirapine is continued beyond 12 weeks if the mother is still breastfeeding and her VL is not yet under 1,000 copies per mL, until it is, or until 4 weeks after breastfeeding stops.

Infant cotrimoxazole prophylaxis (a preventive antibiotic protecting against pneumocystis pneumonia and other infections) is started at 6 weeks of age and continued until the infant is confirmed HIV-negative at 6 weeks after all breastfeeding has stopped.

Dosing is weight-based and is adjusted as the baby grows. The specifics are carried out at the paediatric visits.

Infant HIV testing: the schedule

All HIV-exposed infants follow a defined testing schedule to confirm HIV status over the first 18 to 24 months of life.

Birth HIV PCR: Done in the first days of life. Picks up in-utero transmission. A negative birth PCR is reassuring but does not rule out transmission from delivery or early breastfeeding.

HIV PCR at 10 weeks: Picks up intrapartum transmission. This visit coincides with the 10-week immunisation schedule.

HIV PCR at 6 months: New in the 2019 SA guideline. Picks up early breastfeeding transmission. Coincides with the 6-month well-child immunisation visit. This is an important visit because over 80% of postnatal transmissions occur by 6 months.

Age-appropriate HIV test at 6 weeks after all breastfeeding stops: Essential, even if breastfeeding continues past 18 months of age. A final negative test here confirms the infant is HIV-uninfected.

HIV rapid test at 18 months: Universal screening test for all children, regardless of known HIV exposure. For HIV-exposed infants, confirms the negative status. For children not previously known to be HIV-exposed, provides a catch-all.

Any positive result is confirmed with a repeat PCR on a fresh sample. ART is initiated without waiting for the confirmatory result, because paediatric HIV requires urgent treatment.

These tests are part of routine public-sector PMTCT care and are also available through private pathology labs with medical aid scheme coverage.

Breastfeeding when living with HIV

Breastfeeding is complicated when the mother has HIV. This section deserves honesty.

The 2019 SA PMTCT guideline recommends breastfeeding for 24 months or longer for women with HIV on effective ART with a suppressed viral load, in line with the WHO and with recommendations for the general population, and with the baby on prophylactic nevirapine.

Why the decision is complex:

• U=U has been proven for sexual transmission. It is largely but not entirely proven for breastfeeding transmission. Residual transmission risk in breastfed infants of mothers with sustained undetectable viral load is approximately 0.3 to 1% over the first 6 months.
• Formula feeding eliminates the residual transmission risk but introduces others in the SA context: limited access to clean water, formula costs, stigma around formula feeding as an HIV disclosure, and the real nutritional and immunological benefits of breastfeeding lost.
• The NDoH recommendation balances these trade-offs in favour of breastfeeding for most South African women with HIV, because the overall mortality outcomes for infants are better with breastfeeding on suppressive ART than with formula feeding in typical SA conditions.

This is a conversation, not a formula. The right choice depends on your viral load stability, your access to resources, your community context, and your preferences. We will discuss it before your baby is born and revisit it as circumstances change.

The rationale for breastfeeding with HIV is that breastfeeding has substantial child health benefits (nutrition, immune protection, reduced diarrhoeal and respiratory infection, better developmental outcomes, bonding), and with suppressed ART, the residual HIV transmission risk is very low.

The honest caveat: postnatal transmission risk on ART is very low but is not zero. Rare transmissions have occurred even when maternal viral load was undetectable. U=U (Undetectable equals Untransmittable) applies clearly to sexual transmission and to perinatal (pregnancy and birth) transmission when ART is pre-conception. U=U does not fully apply to breastfeeding. More data are still emerging.

The Dugdale 2025 Lancet analysis found the monthly postnatal transmission risk with maternal viral load under 50 copies per mL is very low (roughly 0.02% per month) but not zero.

What this means in practice:

• If you choose to breastfeed (and most women in SA do, for very good reasons), maintain excellent ART adherence, attend all appointments, have VL checked every 6 months during breastfeeding, and ensure the infant takes prophylaxis as prescribed. If the VL becomes detectable (especially 200 copies per mL or more), the care plan changes urgently: infant prophylaxis intensifies or restarts, and the case is managed as high-priority.
• Exclusive breastfeeding (only breast milk, no formula, no water, no solids) for the first 6 months is recommended. Mixed feeding in the first 6 months (breast plus formula) is associated with higher transmission risk than either exclusive breastfeeding or exclusive formula feeding.
• After 6 months, continue breastfeeding while introducing appropriate complementary foods, up to 24 months or longer.
• When stopping breastfeeding, do so gradually over about a month. Abrupt cessation can cause a rise in breast milk viral load. Infant prophylaxis is continued for 4 weeks after all breastfeeding stops.

Formula feeding is the alternative in specific situations. SA public-sector formula feeding (free formula supply) is reserved for:

• Women whose ART is failing second or third line (VL persistently over 1,000 copies per mL).
• Mothers who have died or infants who have been abandoned.
• Specific medical reasons in the mother or infant.

In the private sector, formula feeding is an option for women who choose it, with thorough counselling on the trade-offs.

This is one of the most important conversations in antenatal HIV care. At NeoHealth, this is an individualised discussion, usually over more than one visit, with Dr Chellan on the HIV side and Dr Lakay on the broader maternal and infant-feeding side. There is no single "right" answer. There is a right answer for each individual woman and her baby.

Postnatal HIV care

South African data (the Khaliq 2026 Free State study and others) repeatedly show that the postnatal period is where viral suppression is most likely to slip. The combination of sleep deprivation, disrupted routines, postnatal depression, breastfeeding demands, and the end of the structured antenatal schedule creates adherence challenges.

The priorities in the first year postpartum:

• Keep the mother-infant pair together in integrated care. One visit, one practice, one team. This is the SA guideline principle and it is how NeoHealth structures these visits.
• Viral load at 6 months, then 6-monthly during breastfeeding. Any rise above 50 triggers review. Any rise above 1,000 triggers infant prophylaxis intensification.
• Screen for postnatal depression. Validated tools, open conversation, low threshold for intervention. Depression is a major driver of adherence problems.
• Contraception. Fertility returns quickly in non-breastfeeding women. Even in breastfeeding women, relying on lactational amenorrhoea for contraception is unreliable beyond the first few months. All hormonal methods including implants (Implanon) and the long-acting injectables are compatible with TLD. The IUD is compatible. A conversation about contraception at the 6-week postnatal visit is standard.
• Ongoing adherence support. Link to mentor mother programmes, MomConnect, or peer support groups if available. The transition from antenatal-style intensive contact to routine follow-up is a vulnerable moment.

For HIV-negative women in pregnancy: prevention matters

If you are HIV-negative at your first antenatal visit, prevention during the pregnancy and breastfeeding period is important.

Why pregnancy is a vulnerability window for HIV acquisition:

• Biological changes in the genital tract.
• Primary HIV infection during pregnancy carries especially high transmission risk to the baby because of very high viral loads during seroconversion.
• Partner dynamics, social pressures, and gender-based violence can all shift during pregnancy.

What the SA guideline recommends:

• Repeat HIV testing at every subsequent antenatal visit. This is the national standard. The Khaliq 2026 study found that in a Free State primary care sample, only 69.6% of HIV-negative women were retested, which is too low. At NeoHealth, repeat testing is part of every antenatal visit for HIV-negative women.
• Condoms for STI prevention and to reduce the risk of new HIV acquisition.
• PrEP (pre-exposure prophylaxis) for women at ongoing risk: those with an HIV-positive partner whose viral suppression is not confirmed, those with multiple partners, those in high-prevalence communities, or those at risk of gender-based violence. The SAHCS 2025 PrEP Guideline supports oral PrEP (TDF/FTC) throughout pregnancy and breastfeeding. Long-acting injectable PrEP (cabotegravir) is a newer option with growing evidence in pregnancy, though availability in SA is still limited.
• Retesting during the breastfeeding period, every 3 months, then annually once breastfeeding has ended.

HIV in pregnancy in South Africa: where we are

South Africa has made remarkable progress in PMTCT over the past two decades. The key milestones:

• 2003: MTCT at 10 weeks after birth was 23%.
• 2015: "Option B+" (lifelong ART for all HIV-positive pregnant women regardless of CD4 count) introduced.
• 2019: New PMTCT guideline introduced TLD as first-line, strengthened postnatal VL monitoring, introduced 6-month PCR, extended recommended breastfeeding duration to 24 months.
• 2024: MTCT at 10 weeks is approximately 0.7%. This is one of the most successful public health programmes in SA history.

But gaps remain. The Khaliq et al. 2026 Free State primary care study (N=668 antenatal records, 2020 to 2023) illustrated several:

• 27.9% HIV prevalence in antenatal attendees.
• 22.4% of women with HIV were newly diagnosed at booking (i.e. had not been tested or had been uninfected at last test).
• 68.1% booked late (after 20 weeks of gestation), losing weeks of potential ART benefit.
• 48.7% of women with HIV had no viral load recorded during pregnancy. This is the single biggest gap: without VL, you cannot confirm suppression, classify the infant's risk, or intervene if adherence is slipping.
• 30.4% of HIV-negative women were not retested during pregnancy, missing potential seroconversions.
• 15% of women with HIV were not on ART.

In the private sector these gaps tend to be smaller (laboratory access is better, appointment structure is tighter), but the underlying challenges (adherence, postnatal loss to follow-up, integration of mother-infant care) apply everywhere.

What it means for women using private GP care in the Garden Route: the infrastructure exists to run a PMTCT programme at standard. The practical gap is consistency. Practice-level protocols, integrated mother-infant visits, structured VL monitoring with result follow-through, and active retesting of HIV-negative women all require deliberate effort.

Co-management at NeoHealth: Dr Chellan and Dr Lakay

A pregnancy with HIV is best served by a care team, not a single clinician. At NeoHealth, Dr Chellan leads the HIV management and Dr Lakay leads the women's health side. The two roles overlap at the patient. The patient does not have to coordinate between us. We do.

Dr Ethan Chellan (Diploma in HIV Management (CMSA)) provides:

• Preconception HIV assessment and counselling.
• ART initiation, optimisation, and ongoing management.
• Viral load and CD4 monitoring.
• Management of drug interactions, side effects, and any treatment failure.
• Postnatal HIV care for the mother.
• HIV testing, prophylaxis, and early follow-up for the infant.
• Coordination with paediatricians for infant PCR testing and early infant diagnosis.

Dr Claudia Lakay (MBChB, women's health focus) provides:

• Preconception women's health: folic acid, screening, contraception discussion.
• Early antenatal care and booking bloods.
• Ongoing antenatal monitoring within the GP scope.
• Cervical screening and postnatal reproductive health.
• Postnatal contraception.
• Mental health screening including postnatal depression.

Neither doctor is a specialist obstetrician. Delivery and the immediate intrapartum period are referred to a specialist obstetrician, usually at Mediclinic George for private patients, or to George Hospital for public-sector patients. What NeoHealth provides is the continuity: preconception, through pregnancy, through delivery coordination, through postnatal mother-infant HIV care. The relationship continues from before pregnancy to well after the baby is walking.

For women who prefer to book directly with an obstetrician for pregnancy care, HIV co-management with NeoHealth is also possible as a parallel arrangement, with results shared between clinicians as needed.

Confidentiality is built into the practice flow. HIV-related consultations are billed and coded under routine primary care categories. There is no separate "PMTCT clinic" label. For women on shared medical aid accounts or with workplace confidentiality concerns, specific billing arrangements are discussed individually.

For any questions about HIV in pregnancy, preconception counselling, ART in pregnancy, viral load monitoring, or postnatal mother-infant follow-up, book a consultation with Dr Chellan and Dr Lakay at NeoHealth. This care sits at the overlap of our HIV management and women's health services.

For Discovery Health members managing HIV in pregnancy, NeoHealth can enrol you on the HIV Care Programme, with both Dr Chellan and Dr Lakay accredited as Premier Plus HIV GPs and able to coordinate ART, viral load monitoring, and antenatal care under one nominated practice.

For urgent PEP enquiries (a possible HIV exposure in the last 72 hours during pregnancy), call the practice immediately. See our PEP article for the full emergency protocol.

Important: This article provides general information on HIV in pregnancy based on current peer-reviewed guidelines, including the SA National Department of Health PMTCT Guideline 2019, the DHHS 2025 Perinatal Guidelines, the SAHCS 2025 PrEP Guideline, and the Dugdale 2025 Lancet meta-analysis. It is intended for educational purposes only. It is not personalised medical advice. Every pregnancy is different. Please seek individual clinical care from a qualified healthcare provider for any HIV in pregnancy questions.

Sources and references

• SAHCS PMTCT Guidelines. Guidelines for the prevention of mother-to-child transmission of HIV. Southern African HIV Clinicians Society.
• NDoH Knowledge Hub. PMTCT Clinical Guidelines. South African National Department of Health.
• Zash R et al. Tsepamo. Neural-tube defects and antiretroviral treatment regimens in Botswana. NEJM 2019 (PubMed).
• World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring. WHO.
• HIVinfo.NIH.gov. Perinatal HIV clinical guidelines. US DHHS.
• Rodger AJ et al. PARTNER2. Risk of HIV transmission in serodifferent couples with suppressive ART. Lancet 2019 (PubMed).
• NICHD. HIV and pregnancy research and guidelines. Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Content on this page is based on these sources and current clinical practice at NeoHealth. It is general health information, not personalised medical advice. Book a consultation for individual assessment.