AFJOG

REVIEW African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 3 | 2024 | Pre-Exposure Prophylaxis to prevent HIV infection during Pregnancy and Breast-feeding: A South African Perspective INTRODUCTION The HIV-1 epidemic is a global catastrophe. For the past four decades,humanimmunodeficiencyvirus type-1(HIV-1) infection has had a huge impact on people’s lives. This novel retro-viral infection, causing acquired immunodeficiency syndrome (AIDS) was first described in 1981 by Michael Gottlieb and his team (1) . Two variants of the virus have been identified (HIV-1 & HIV- 2), with the former being more prevalent worldwide (2) . Despite the widespread availability of highly active antiretroviral therapy (ART), new HIV infections continue to be reported. An estimated 1.5 million new infections are reported globally each year (3,4) . HIV disproportionately affects Eastern and Southern African (ESA) countries, and specifically adolescent girls and young women (AGYW) (5,6,7) . South Africa has the largest HIV epidemic in the world, with 7.5 million people living with HIV and a national prevalence of 27.5% as of 2021 (8) . South Africa’s epidemic represents 20% of the global HIV burden (9) . In 2015, AGYW (15–24yrs.) accounted for 25% of new HIV infections among adults in ESA (10) . This represents one out of every four new HIV infections, with an estimated 1,000 AGYW acquiring HIV on a daily basis. Stigma, poverty, gender-based violence and social disparities are major contributors to this effect. In South Africa, the HIV incidence amongst AGYW who are not on pre-exposure prophylaxis (PrEP) has been reported at 3.5 per 100 person-years (11) . Coincidentally, this population of women experiences the highest proportion of unintended pregnancies, with a profound effect on perinatal transmission of HIV (12) . Approximately 29% of pregnant women attending antenatal care are HIV-infected in South Africa (13) . Without the availability of ART, perinatal transmissions of HIV have been reported at 15 - 45% (14) . The widespread use of ART for all individuals who tested positive for HIV, irrespective of CD4 count, has resulted in a drastic reduction in the rates of HIV perinatal transmissions world-wide. As of 2019, 85% of women have access to antiretroviral therapy globally (14) . South Africa has the largest HIV treatment program in the world with a 98.8% coverage (8,15) . The elimination of mother-to-child transmission (EMTCT) of HIV is now feasible, more than ever before. EMTCT of HIV aims at reducing perinatal HIV infections by 75% or achieving a vertical transmission (VT) rate of < 1% (16,17,18) . So far, Botswana is the only low-middle income African country to have achieved this target (18) . In South Africa, the perinatal transmission of HIV has been reported at < 2% (19,20) The prevention of new HIV infections among target populations is one of the leading strategies to reduce the rate of perinatal transmissions (18) . Daily oral antiretroviral drugs are currently the method of choice for the prevention of HIV- 1 acquisition worldwide. The effectiveness of oral PrEP rests on proper drug compliance. Other novel classes and delivery methods of ARV drugs (e.g. vaginal rings, injectables, implants, vaccines etc) have been developed and evaluated (21) . However, the safety and efficacy of some of these agents during pregnancy and lactation has not been fully elucidated. There is currently a huge gap in the literature on PrEP options for pregnant and breastfeeding women (PBFW) (22) . People who inject drugs, AGYW, PBFW, men having sex with men (MSM), transgender and gender diverse individuals, are all key target populations for PrEP (22,23) . This literature review is aimed at evaluating PrEP options for the prevention of incidental HIV infections during pregnancy and lactation. Their availability, efficacy and safety will be scrutinized further. Pre-exposure prophylaxis (PrEP) involves taking a pharmaceutical agent prior to exposure toapathogen, in-order to prevent an outcome. Pre-exposure prophylaxis for HIV involves the use of antiretroviral (ARV) drugs to prevent HIV infection. Antiretroviral therapy may be indicated for pre-exposure and post-exposure prophylaxis, and for the lifelong treatment of HIV infection (see Box 1 below). The use of antiretroviral therapy for PrEP is an important milestone in the global quest to eradicate new HIV infections and in the process, eliminate perinatal transmissions. All HIV-negative individuals, including pregnant women, who are deemed to be at a substantial risk of acquiring HIV are eligible for PrEP, as per WHO guidance (see Box 2 below) (5,6,22,24) . Ndlovu DH, Matsela L Department of Obstetrics and Gynaecology Sefako Makgatho Health Sciences University, Pretoria, South Africa CORRESPONDENCE: DH Ndlovu | Email: dumisanindlovu37@yahoo.com Pre-Exposure Prophylaxis to prevent HIV infection during Pregnancy and Breast- feeding: A South African Perspective ABSTRACT HIV infection represents a global catastrophe. Despite the availability of highly active antiretroviral drugs, new HIV infections continue to be reported worldwide. The pandemic impacts Eastern and Southern African Countries more than any other part of the world, with South Africa taking center stage. Pregnant and breastfeeding women, together with adolescent girls and young women, are a particularly vulnerable population group. The prevention of primary HIV infection provides an opportunity for the eradication of HIV perinatal transmissions, as espoused by WHO. Great strides have been made over the past decade, with more options for pre-exposure prophylaxis having being made available to individuals at risk of HIV acquisition. Some of these products are critical, as they empower women to take control of their own sexual health choices. As a result of ethical considerations, pregnant and lactating women have largely been excluded from pivotal trials on pre-exposure prophylaxis. There are limited data on the available options for prevention of new HIV infections during pregnancy and lactation. Pregnant and breastfeeding women must be considered in on-going and planned trials, as frameworks for safe and ethical inclusion have already been pioneered. There is lack of awareness and poor uptake of pre-exposure prophylaxis, especially among target populations. Keywords: HIV, Pre-exposure prophylaxis, adolescent girls and young women, pregnant and breastfeeding women, fixed-dose combinations, elimination of mother-to-child transmission, adherence, long-acting antiretroviral therapy, microbicides, vaccines. African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 3 | 2024 | 07