New strategies required to protect mothers and infants who are still getting HIV

15 May 2025

Over the past two decades, South Africa made massive progress in reducing transmission of HIV from mothers to their babies. Even so, about 7,000 babies still contract the virus every year. Experts put this down to having the right puzzle pieces for prevention but failing to integrate them optimally.

About 7,000 infants in South Africa still contract HIV from their mothers every year — a stark reminder that, while significant progress has been made in preventing mother-to-child transmission (MTCT), that progress has somewhat plateaued.

Twenty years ago, there were 10 times as many — about 70,000 — new infections per year in babies. Today, the MTCT rate has dropped from a peak of over 30% at the turn of the century to about 2.7%.

The story is mainly one of antiretroviral medicines helping suppress the virus in the bodies of mothers living with HIV, thus protecting tens of thousands of babies over the years. But the story is also one of progress that has slowed in recent years — while South Africa’s MTCT rate lingers well above 2%, it is at or below 1% in several developed countries.

About a decade ago, South Africa was making great progress towards reducing new HIV infections among children and keeping their mothers alive, but that has been followed by some complacency, says Professor Linda-Gail Bekker, CEO of the Desmond Tutu Health Foundation and Director of the Desmond Tutu HIV Centre.

As pointed out by Professor Adrian Puren, Executive Director of the National Institute for Communicable Diseases and the the head of its Centre for HIV and Sexually Transmitted Infections, “although the vertical transmission (another term for MTCT) rate is low, because of the high burden of maternal HIV, the absolute number of vertical transmissions remains high”.

As pointed out by Dr Glenda Gray, a Distinguished Professor at the University of the Witwatersrand: “We have very high rates of HIV in pregnant women in South Africa. About a third of all women in our country who are pregnant are HIV infected, and it’s even higher in some parts of KwaZulu-Natal and particularly in young women.”

An evolving problem

The progress of the past two decades is largely due to increased access to antiretroviral therapy and how well the medicines suppress the virus in a person’s body. If a mother living with HIV is stable on treatment, the chances are very close to zero that the virus will be transmitted to her baby.

In the public sector, pregnant women are routinely tested for HIV and offered antiretroviral therapy if positive. A complication, however, emerges when a woman contracts HIV late in pregnancy or in the months after birth and the virus is then transmitted to her baby via breastfeeding before she is diagnosed and can start the treatment that will suppress the virus.

The latest estimates from Thembisa, the leading mathematical model of HIV in South Africa, suggest that this dynamic is indeed driving much of the MTCT in the country. Of the approximately 7,200 babies who contracted HIV in South Africa from mid-2023 to mid-2024, only 2,500 became positive before or at birth. The rest of the transmissions occurred during breastfeeding in the months after birth. While a portion of these mothers were on antiretroviral therapy, the majority had not been diagnosed with HIV yet.

HIV-exposed infants are at particularly high risk if the mother was recently infected. As Bekker explains, this is because a person who has just acquired HIV has a very high amount of the virus in their body, since their immune system hasn’t had time to fight it yet, making it easier to pass the virus on.

“So, you get very high viral loads, and this is therefore a very dangerous time for vertical transmission,” she says.

Dvora Joseph Davey, an associate professor of epidemiology at the University of California, Los Angeles, and the University of Cape Town, concurs.

“We know that in South Africa, over a third of HIV in infants is due to getting HIV from their mothers who were HIV-negative at their first antenatal visit, and they acquired HIV at some point during pregnancy or lactation,” she says.

She explains that MTCT is in part due to inequity in healthcare. Mother-to-child transmissions often occur in certain pockets, such as in rural areas, because of limited access to prevention methods, late diagnosis, not starting treatment on time, and coming into antenatal care late.

“This points to missed opportunities in sustaining maternal antiretroviral therapy adherence and viral suppression throughout the breastfeeding window — an area where we urgently need more targeted and consistent support,” says Olwethu Mlanzeli, who leads Communications and Advocacy for the youth HIV-focused initiative Africa Reach.

What to do?

South Africa’s 2023 guidelines for preventing vertical transmission (of several infectious diseases) does cover several of the issues experts raised in interviews with Spotlight. Among others, the guidelines recommend that pregnant women or new mothers who are newly diagnosed with HIV should be started on a dolutegravir-based antiretroviral regimen, since dolutegravir is particularly effective at rapidly suppressing the virus. The guidelines prescribe testing babies for HIV at birth, 10 weeks, and at six and 18 months.

But in South Africa, good guidelines are not always followed by universal implementation. In line with this, several experts firstly suggest simply strengthening existing HIV treatment and prevention services, particularly those aimed at women before, during and in the months after pregnancy.

It is suggested that women should continually be offered HIV testing during all stages of pregnancy and after birth. Joseph Davey says this needs to be integrated better, so that the same nurse offers contraceptives, HIV testing and HIV prevention medicines, proactively. Her research has shown that, at least on a small scale, training clinics to integrate the services can work well.

Puren notes that the integration of MTCT care could also be done by joining HIV testing with infant immunisation programmes.

“There doesn’t need to be a major overhaul,” adds Joseph Davey. “These are simple steps related to data collection and targets around HIV testing that can be implemented within existing standards of care.”

Experts also suggest that it is crucial to put women and babies on HIV treatment and HIV-prevention treatment as widely as possible during the postnatal phase. Joseph Davey cautions that these interventions are not the same across the country. The Western Cape, for instance, has explicit guidelines around HIV prevention medicines and pregnancy that have been updated every few years, while this does not seem to be the case for other provinces. Joseph Davey says that expanding this could be helpful.

But even with good guidelines, there are barriers to adherence. Bekker notes that a daily HIV prevention regimen may be difficult to take for a pregnant woman experiencing morning sickness, or while she is a new parent.

“So here comes the perfect opportunity for long-acting injectable pre-exposure prophylaxis, such as cabotegravir or hopefully, in the future, lenacapavir,” she says.

Not widely available

Cabotegravir injections provide two months of protection against HIV infection per shot and lenacapavir six months per shot. Neither is yet widely available in South Africa. Cabotegravir is registered here, and lenacapavir’s registration is expected in the next six months or so.

There are other potential advances, according to Gray, that could make a significant difference.

“Antiretrovirals can mop up and control a lot, but to eradicate breast milk transmission we need other monoclonal antibodies or an HIV vaccine. And so, if we really are committed to eradicating paediatric HIV, then we need more tools besides antiretroviral therapies in the toolbox.”

For now, these alternatives to antiretrovirals remain experimental and none have been proven to work or been approved for use by regulatory authorities.

Lastly, Mlanzeli notes that patient awareness is a key part of the challenge, especially during the postnatal period.

“There’s a need for greater investment and visibility around prevention of MTCT programmes, particularly in the postnatal period,” she says. “While many governments allocate substantial resources to HIV programmes overall, these resources don’t always translate into strengthened support for mothers and infants.”

Brodie Daniels, Specialist Scientist at the HIV and other Infectious Diseases Research Unit at the South African Medical Research Council, agrees. “What we need to focus on now is educating women on the increased risks during pregnancy and breastfeeding if they are HIV-uninfected during their antenatal visits,” she says. “Women need to be encouraged to test more often during these periods, so that if they do seroconvert, both they and their infant can be placed on prophylaxis.”

Impact of aid cuts

In recent months, large and abrupt cuts to HIV funding from the United States government have severely disrupted HIV services in South Africa and neighbouring countries. While some limited funds are still flowing, it is a small fraction of what there was previously and there is little hope that funding will be restored.

Several researchers Spotlight spoke to are very worried that the cuts will negatively impact MTCT rates. The cutting of some services, specifically those aimed at marginal groups, will probably lead to many not being able to access HIV counselling, prevention and testing services in a timely manner. Thus, the number of women contracting HIV while pregnant or breastfeeding and not being virally controlled may increase.

But the silver lining is that change is within reach, if the resources are available and implementation is done right. As Bekker puts it: “We know exactly what we need to do, and it’s not like we don’t have the tools. We need to just do it!” DM

This article was first published by Spotlight – health journalism in the public interest. Sign up to the Spotlight newsletter.

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South Africa

An evolving problem

What to do?

Not widely available

Impact of aid cuts