Optimising Post-Delivery Viral Load Monitoring and HIV Care to Eliminate Breastfeeding-Associated HIV Transmission in Sub-Saharan Africa: A Review.

Sustained maternal HIV viral-load (VL) suppression during breastfeeding is essential for eliminating vertical HIV transmission in Sub-Saharan Africa. Although vertical transmission prevention programmes have improved antiretroviral therapy coverage and peripartum outcomes, viral control may deteriorate after delivery. This decline may result from psychosocial stressors, fragmented mother-infant services, and delayed return of results. This review examines post-delivery VL dynamics, breastfeeding-associated transmission risk, and the limitations of binary suppression thresholds. We suggest that post-delivery VL monitoring should be implemented as a rapid-action pathway. In this approach, detectable viraemia during breastfeeding should prompt a timely reassessment of adherence and repeat VL testing. Regimen review and additional measures to reduce the risks for both the mother and infant should be implemented where indicated. We also examine the individual, relational, structural, and health system determinants of post-delivery viraemia and lost to follow-up, including intimate partner violence. Finally, we highlight service delivery innovations that may improve maternal VL suppression and HIV-free infant survival rates.