Nisha Jacob

Background: In South Africa, HIV treatment guideline changes implemented in 2020 introduced dolutegravir-based regimens and expanded viral load (VL) monitoring to include testing at delivery and 6 months postpartum for women on antiretroviral therapy (ART). We assessed temporal trends and factors associated with VL monitoring and outcomes among pregnant and postpartum women with HIV in the Western Cape. Methods: We included women with HIV with live births from 2018-2024 who initiated ART before or during pregnancy. We used routinely-collected healthcare data to assess VL monitoring at (i) delivery or third trimester (“late pregnancy”), and (ii) postpartum (<8 months after delivery). VL categories were defined as <50, 50-999, and ≥1,000 copies/ml. We examined predictors of VL testing coverage and viral suppression using modified Poisson GEE and multinomial logistic regression models, including policy period, maternal age, parity, and ART timing . Results: Among 88,415 deliveries to 80,095 women: 74% received ART before pregnancy and 26% started ART during pregnancy. From 2018-2024, late-pregnancy VL testing coverage increased: 69%-91% (aRR=1.28, 95%CI 1.26-1.29); whereas postpartum testing coverage declined: 51%-43% (aRR=0.96, 95%CI 0.94-0.97). The proportion of women with late-pregnancy VL<50 increased from 73-80% (2018-2024), while VL 50-999 declined from 14%-8%. ART interruptions before or during pregnancy, younger age and higher parity were predictors of lower VL testing coverage and poorer virological outcomes. Conclusion: Updated ART guidelines improved late-pregnancy but not postpartum VL testing coverage. Dolutegravir introduction was associated with improved viral suppression <50 copies/ml. Persistently low postpartum coverage suggests substantial gaps in retention and/or VL testing.

Introduction: Despite universal HIV test-and-treat policy in South Africa, vertical transmission continues to occur. We evaluated the temporal effectiveness of vertical transmission prevention (VTP) over three maternal antiretroviral therapy (ART) policy periods (three-drug ART accessible to those with CD4 counts <200 cells/µl (January 2010 – March 2010); < 350 cells/µl (April 2010 – April 2013); and lifelong ART regardless of CD4 count (May 2013 – December 2020)) in Western Cape, South Africa using public sector routine individuated data. Methods: We conducted a retrospective cohort study with child HIV infection as the primary outcome. The cohort of 842 641 pregnancies from 2010–2020, inclusive of child HIV exposure, maternal ART, and child outcomes, was enumerated using administrative, laboratory and pharmacy data. Multivariable logistic regression was used to explore associations with vertical transmission. Results: The proportion of pregnant women living with HIV (WLWH) initiating ART prior to pregnancy increased from 20.9% in 2010 to 71.1% in 2020. Of all pregnancies 17.1% (143 987/842 641) were HIV exposed and 16.3% (137 572/842 641) had a record of a child HIV outcome, of whom 3966 (2.9%) were HIV positive by 24 months. Among children with known maternal HIV exposure (143 987), 32.0% had unknown HIV status and 2.1% were diagnosed with HIV by study closure. In 2020, HIV status was ascertained in 87.2% (16 908/19 382) of children exposed to HIV. Children born in policy period 3 were less likely to have HIV than children born in policy period 2 (aOR 0.66; 95% CI 0.60–0.72), mediated through expanded ART access. Between 2017 and 2020, 16.5% of child HIV diagnoses were from pregnancies without maternal HIV exposure records. Young maternal age, no antenatal ART, previous tuberculosis and no records of antenatal visits were associated with vertical transmission in all periods. Conclusions: Using routine data, we report an increase in WLWH initiating ART prior to pregnancy, and a decline in vertical transmission of HIV over three policy periods. Although HIV diagnosis amongst children exposed to HIV has reduced over time, the proportion of infections in children without established exposure emphasises the need to optimise VTP opportunities.

Introduction: Despite universal HIV test-and-treat policy in South Africa, vertical transmission continues to occur. We evaluated the temporal effectiveness of vertical transmission prevention (VTP) over three maternal antiretroviral therapy (ART) policy periods (three-drug ART accessible to those with CD4 counts <200 cells/µl (January 2010 – March 2010); <350 cells/µl (April 2010 – April 2013); and lifelong ART regardless of CD4 count (May 2013 – December 2020)) in Western Cape, South Africa using public sector routine individuated data. Methods: We conducted a retrospective cohort study with child HIV infection as the primary outcome. The cohort of 842 641 pregnancies from 2010 – 2020, inclusive of child HIV exposure, maternal ART, and child outcomes, was enumerated using administrative, laboratory and pharmacy data. Multivariable logistic regression was used to explore associations with vertical transmission. Results: The proportion of pregnant women living with HIV (WLWH) initiating ART prior to pregnancy increased from 20.9% in 2010 to 71.1% in 2020. Of all pregnancies 17.1% (143 987/842 641) were HIV exposed and 16.3% (137 572/842 641) had a record of a child HIV outcome, of whom 3966 (2.9%) were HIV positive by 24 months. Among children with known maternal HIV exposure (143 987), 32.0% had unknown HIV status and 2.1% were diagnosed with HIV by study closure. In 2020, HIV status was ascertained in 87.2% (16 908/19 382) of children exposed to HIV. Children born in policy period 3 were less likely to have HIV than children born in policy period 2 (aOR 0.66; 95% CI 0.60 – 0.72), mediated through expanded ART access. Between 2017 and 2020, 16.5% of child HIV diagnoses were from pregnancies without maternal HIV exposure records. Young maternal age, no antenatal ART, previous tuberculosis and no records of antenatal visits were associated with vertical transmission in all periods. Conclusions: Using routine data, we report an increase in WLWH initiating ART prior to pregnancy, and a decline in vertical transmission of HIV over three policy periods. Although HIV diagnosis amongst children exposed to HIV has reduced over time, the proportion of infections in children without established exposure emphasises the need to optimise VTP opportunities.

Monitoring progress of HIV programmes is reliant on robust surveillance. The WHO Consolidated guidelines on person-centred HIV strategic information recommend moving towards using routine programmatic data for HIV surveillance rather than seroprevalence surveys which are costly and inefficient. In the Western Cape province of South Africa, public-sector individual-level routine data from various sources are linked on a unified platform through the Provincial Health Data Centre (PHDC). This allows monitoring of provincial antenatal HIV seroprevalence over time. We assessed the validity of these routine individuated data compared to aggregated program data and population-wide sentinel antenatal HIV seroprevalence surveys for the Western Cape. We conducted a retrospective cohort analysis of pregnancies identified in the PHDC from January 2011 to December 2020. Unique identifiers were used to link antenatal and HIV care records from routine electronic systems. HIV prevalence estimates were compared with available antenatal seroprevalence survey estimates and register-based aggregate program data from the District Health Information System. Provincial, district-level and age-group HIV prevalence estimates were compared between data systems using correlation coefficients, absolute differences and trend analysis. Of the 977,800 pregnancies ascertained, PHDC HIV prevalence estimates from 2011 to 2013 were widely disparate from aggregate and survey data (due to incomplete electronic data), whereas from 2014 onwards, estimates were within the 95% confidence interval of survey estimates, and closely correlated to aggregate data estimates (r = 0.8; p = 0.01), with an average prevalence difference of 0.4%. PHDC data show a slow but steady increase in provincial HIV prevalence from 16.7% in 2015 to 18.6% in 2020. The highest HIV prevalence was in the Cape Metro district (20.3%) Prevalence estimates by age group were comparable between sentinel surveys and PHDC from 2015 onwards, with prevalence estimates stable over time among younger age-groups (15–24 years) but increased among older age-groups (> 34 years). This study compares sentinel seroprevalence surveys with both routine register-based aggregate data and individuated data. Based on recent estimates, we show that in this setting linked individuated data may be reliably used for HIV prevalence surveillance and provide more granular estimates with improved efficiency compared to seroprevalence surveys and register-based aggregate data.

Background: Accurate measurement of antenatal antiretroviral treatment (ART) coverage in pregnancy is imperative in tracking progress towards elimination of vertical HIV transmission. In the Western Cape, South Africa, public-sector individual-level routine data are consolidated from multiple sources, enabling the description of temporal changes in population-wide antenatal antiretroviral coverage. We evaluated the validity of different methods for measuring ART coverage among pregnant women. Methods: We compared self-reported ART data from a 2014 antenatal survey with laboratory assay data from a sub-sample within the survey population. Thereafter, we conducted a retrospective cohort analysis of all pregnancies consolidated in the Provincial Health Data Centre (PHDC) from January 2011 to December 2020. Evidence of antenatal and HIV care from electronic platforms were linked using a unique patient identifier. ART coverage estimates were triangulated with available antenatal survey estimates, aggregated programmatic data from registers recorded in the District Health Information System (DHIS) and Thembisa modelling estimates. Results: Self-reported ART in the 2014 sentinel antenatal survey (n = 1434) had high sensitivity (83.5%), specificity (94.5%) and agreement (k = 0.8) with the gold standard of laboratory analysis of ART. Based on linked routine data, ART coverage by the time of delivery in mothers of live births increased from 67.4% in 2011 to 94.7% by 2019. This pattern of increasing antenatal ART coverage was also seen in the DHIS data, and estimated by the Thembisa model, but was less consistent in the antenatal survey data. Conclusion: This study is the first in a high-burden HIV setting to compare sentinel ART surveillance data with consolidated individuated administrative data. Although self-report in survey conditions showed high validity, more recent data sources based on self-report and medical records may be uncertain with increasing ART coverage over time. Linked individuated data may offer a promising option for ART coverage estimation with greater granularity and efficiency.

Introduction: Monitoring mother‐infant pairs with HIV exposure is needed to assess the effectiveness of vertical transmission (VT) prevention programmes and progress towards VT elimination.Methods: We used routinely collected data on infants with HIV exposure, born May 2018–April 2021 in the Western Cape, South Africa, with follow‐up through mid‐2022. We assessed the proportion of infants diagnosed with HIV at birth (≤7 days), 10 weeks (>1 to 14 weeks) and >14 weeks as proxies for intrauterine, intrapartum/early breastfeeding and late breastfeeding transmission, respectively. We used mixed‐effects Poisson regression to assess factors associated with VT in mothers known with HIV by delivery.Results: We included 50,461 infants born to mothers known with HIV by delivery. HIV was diagnosed in 894 (1.8%) infants. Among mothers, 51% started antiretroviral treatment (ART) before and 27% during pregnancy; 17% restarted during pregnancy after ≥6 months interruption; and 6% had no recorded ART during pregnancy. Most pregnancy ART regimens included non‐nucleoside reverse transcriptase inhibitors (83%). Of mothers with available results (90% with viral load [VL]; 70% with CD4), VL nearest delivery was 14 weeks. Among these infants, 0.9%, 0.4% and 1.5% were diagnosed positive at birth, 10 weeks and >14 weeks, respectively. Among infants diagnosed with HIV, 43%, 16% and 41% were diagnosed at these respective time periods. Among mothers with VL<100, 100–999, 1000–99,000 and ≥100,000 copies/ml nearest delivery, infant HIV diagnosis incidence was 0.4%, 2.3%, 6.6% and 18.4%, respectively. Increased VT was strongly associated with recent elevated maternal VL with a seven‐fold increased rate with even modestly elevated VL (100–999 vs. <100 copies/ml). VT was also associated with unknown/low maternal CD4, maternal age <20 years, no antenatal ART, later maternal ART start/restart in pregnancy and ART gaps.Conclusions: Despite high maternal ART coverage and routine postnatal prophylaxis, ongoing VT remains a concern. Timing of infant HIV diagnoses suggests intrapartum and/or breastfeeding transmission in nearly 60%. Interventions to ensure retention on ART and sustained maternal viral suppression are needed to reduce VT.

Background: Accurate measurement of antenatal antiretroviral treatment (ART) coverage in pregnancy is imperative in tracking progress towards elimination of vertical HIV transmission. In the Western Cape, South Africa, public-sector individual-level routine data are consolidated from multiple sources, enabling the description of temporal changes in population-wide antenatal antiretroviral coverage. We evaluated the validity of different methods for measuring ART coverage among pregnant women. Methods: We compared self-reported ART data from a 2014 antenatal survey with laboratory assay data from a sub-sample within the survey population. Thereafter, we conducted a retrospective cohort analysis of all pregnancies consolidated in the Provincial Health Data Centre (PHDC) from January 2011 to December 2020. Evidence of antenatal and HIV care from electronic platforms were linked using a unique patient identifier. ART coverage estimates were triangulated with available antenatal survey estimates, aggregated programmatic data from registers recorded in the District Health Information System (DHIS) and Thembisa modelling estimates. Results: Self-reported ART in the 2014 sentinel antenatal survey (n=1434) had high sensitivity (83.5%), specificity (94.5%) and agreement (k=0.8) with the gold standard of laboratory analysis of ART. Based on linked routine data, ART coverage by the time of delivery in mothers of live births increased from 67.4% in 2011 to 94.7% by 2019. This pattern of increasing antenatal ART coverage was also seen in the DHIS data, and estimated by the Thembisa model, but was less consistent in the antenatal survey data. Conclusion: This study is the first in a high-burden HIV setting to compare sentinel ART surveillance data with consolidated individuated administrative data. Although self-report in survey conditions showed high validity, more recent data sources based on self-report and medical records may be uncertain with increasing ART coverage over time. Linked individuated data may offer a promising option for ART coverage estimation with greater granularity and efficiency.

Background: HIV diagnosis in South Africa is based on a point-of-care testing (PoCT) algorithm with paper-based record-keeping. Aggregated testing data are reported routinely. To facilitate improved HIV case-based surveillance, the Western Cape Province implemented a unique pilot intervention to digitise PoCT results, at an individual level, and generate an electronic register using the newly developed Provincial Health Data Centre (PHDC). We describe the intervention (phased) and present an evaluation of the operational feasibility of the intervention. We also offer implementation insights into establishing electronic capture of individual level testing data. Methods: Cross-sectional analyses were conducted on records of all patients attending a local Community Health Centre who had an HIV-PoCT during the study period. Data from the intervention were linked to the PHDC using a unique identifier and compared with aggregate data from the paper-based register. Correlation coefficients were calculated to quantify the correlation between the two monthly datasets. To support an understanding of the findings, the Department of Health project management team generated reflections on the implementation process, which were then grouped thematically into implementation lessons. Results: In total, 11,337 PoCT records were digitised (70% (7954) during Phase I; and 30% (3383) during Phase II). Linkage of forms to the PHDC was 96% in Phase I and 98% in Phase II. Comparison with aggregate data showed high correlation during Phase I, but notable divergence during Phase II. Divergence in Phase II was due to stringent data quality requirements and high clinical staff turnover. Factors supporting implementation success in Phase I included direct oversight of data capturing by a manager with clinical and operational insight. Implementation challenges included operational, health system, and high cost-related issues. Conclusions: We demonstrate that rapid digitisation of HIV PoCT data, without compromising currently collected aggregate data, is operationally feasible, and can contribute to person-level longitudinal HIV case-based surveillance. To take to scale, we will need to improve PoCT platforms and clerical and administrative systems. Although we highlight challenges, we demonstrate that electronic HIV testing registers can successfully replace manual registers and improve efforts to monitor and evaluate HIV testing strategies.

Background HIV diagnosis in South Africa is based on a point-of-care testing (PoCT) algorithm with paper-based record-keeping. Aggregated testing data are reported routinely. To facilitate improved HIV case-based surveillance, the Western Cape Province implemented a unique pilot intervention to digitise PoCT results, at an individual level, and generate an electronic register using the newly developed Provincial Health Data Centre (PHDC). We describe the intervention (phased) and present an evaluation of the operational feasibility of the intervention. We also offer implementation insights into establishing electronic capture of individual level testing data. Methods Cross-sectional analyses were conducted on records of all patients attending a local Community Health Centre who had an HIV-PoCT during the study period. Data from the intervention were linked to the PHDC using a unique identifier and compared with aggregate data from the paper-based register. Correlation coefficients were calculated to quantify the correlation between the two monthly datasets. To support an understanding of the findings, the Department of Health project management team generated reflections on the implementation process, which were then grouped thematically into implementation lessons. Results In total, 11 337 PoCT records were digitised (70% (7954) during Phase I; and 30% (3383) during Phase II). Linkage of forms to the PHDC was 96% in Phase I and 98% in Phase II. Comparison with aggregate data showed high correlation during Phase I, but notable divergence during Phase II. Divergence in Phase II was due to stringent data quality requirements and high clinical staff turnover. Factors supporting implementation success in Phase I included direct oversight of data capturing by a manager with clinical and operational insight. Implementation challenges included operational, health system, and high cost-related issues. Conclusions We demonstrate that rapid digitisation of HIV PoCT data, without compromising currently collected aggregate data, is operationally feasible, and can contribute to person-level longitudinal HIV case-based surveillance. To take to scale, we will need to improve PoCT platforms and clerical and administrative systems. Although we highlight challenges, we demonstrate that electronic HIV testing registers can successfully replace manual registers and improve efforts to monitor and evaluate HIV testing strategies.