HIV is the main cause of death among pregnant women in Johannesburg, South Africa's most populous city, according to a five-year study of maternal mortality at one of the city's largest public hospitals.
The study, published in the August 2009 issue of Obstetrics and Gynaecology, found that the maternal mortality ratio was more than six times higher in HIV-positive women (776 deaths per 100,000 births) than in HIV-negative women (124 per 100,000). Nearly half of the 108 women who passed away between 2003 and 2007 died from HIV-related causes, most commonly tuberculosis and pneumonia.
Although most of those who died had a CD4 count (which measures immune system strength) well below 200 - the current threshold for starting treatment - and were eligible for antiretroviral (ARV) drugs, the roll-out of treatment a year into the study period did not reduce maternal deaths among the HIV-infected women because only two had started taking the medication.
"The problem is not that ARVs don't reduce mortality," said Dr Vivian Black, of the Reproductive Health and HIV Research Unit (RHRU) at the University of Witwatersrand, Johannesburg, lead of author of the study. Only one maternal death was recorded in about 2,000 HIV-positive women receiving ARVs from an RHRU programme.
The study highlights gaps in the country's prevention of mother-to-child HIV transmission (PMTCT) programme that are causing HIV-positive women to miss out on testing and treatment.
HIV testing rates increased more than threefold during the study period, yet the authors still identified insufficient HIV testing as "the most important programmatic weakness".
Between 28 percent and 33 percent of women attending antenatal clinics in South Africa are HIV positive, but many remain unaware of their status and never access the necessary care to prevent transmission to their infants or protect their own health.
The study identified a link between low prenatal clinic attendance and high mortality rates among HIV-positive women, but Black also pointed to the lack of postnatal services for HIV-positive mothers, especially those who are not eligible for ARVs. "Post-partum [after birth] is when we see the bulk of deaths," she told IRIN/PlusNews.
Black would like to see PMTCT programmes extended to include a greater focus on long-term maternal health. "If you look after the health of the woman she's less likely to transmit the virus, but securing mum's health is important because of broader issues," she said.
The study findings are likely to contribute to the heated debate in South Africa's HIV/AIDS sector about the need to raise the threshold for starting treatment from a CD4 count of 200 to 350.
The South African National AIDS Council (SANAC) recommended the change after findings from a number of recent studies showed that patients who started treatment earlier developed fewer AIDS-related illnesses and had lower mortality rates, but the National Health Council, an advisory body to the health ministry, has yet to approve raising the threshold to 350.
HIV-positive pregnant women are between 1.5 and five times more at risk of maternal death than HIV-negative women, according to a number of studies cited in the RHRU study, so giving them ARV treatment earlier is particularly important.
The authors conclude that the deaths of most of the HIV-positive women in the study could have been avoided if they had begun ARV treatment, and been given cotrimoxazole prophylaxis [an antibiotic that helps prevent opportunistic infections].
"We'd like to see [a CD4 threshold of] 350 across the board," said Black, "but if there's an inability to do that immediately, we would be grateful if they'd prioritize pregnant women, and those with TB."
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