Abstract

Background: The Eastern Cape Province carries the second-highest antenatal HIV prevalence nationally (32.9%), yet province-level longitudinal data on HIV incidence among pregnant and breastfeeding women (PBW) remain limited. This study examined trends in HIV incidence, HIV prevalence, mother-to-child transmission (MTCT), and antiretroviral therapy (ART) coverage among PBW in the Eastern Cape from 2000 to 2023. Methods: A quantitative ecological design was employed using secondary analysis of modelled estimates from the Thembisa Provincial HIV Model, version 4.8. Annual HIV incidence in PBW, HIV prevalence in pregnant women (overall and by five-year maternal age group), MTCT rate, new MTCT cases, and ART coverage were extracted with 95% confidence intervals (CIs) for the Eastern Cape, 2000–2023. Descriptive analysis characterised temporal trends at seven reference years, and formal trend significance was assessed using the Mann–Kendall test and log-linear regression. Results: HIV incidence in PBW declined from 3.8% (95% CI: 3.7–3.9) in 2000 to 1.8% (95% CI: 1.3–2.4) in 2023, a relative reduction of approximately 53%. ART coverage rose from 0% to 71.6%, coinciding with an 88% reduction in MTCT rate from 31.3% to 3.6%. By 2023, the MTCT rate had crossed below the World Health Organization 5% elimination threshold. HIV prevalence among pregnant women remained high at 25.0% despite declining incidence. The age distribution of HIV burden shifted markedly toward older maternal cohorts: prevalence among women aged 40–49 years increased from 9.9% in 2000 to 46.5% in 2023, while prevalence in the 15–24 age group declined substantially. New MTCT cases fell from 9990 in 2000 to 1236 in 2023. Conclusions: Declining HIV incidence in PBW coincided with substantial ART scale-up in the Eastern Cape, while HIV prevalence among pregnant women remained persistently high, a divergence that reflects the accumulating, ART-sustained pool of women living with HIV who survive into older reproductive age rather than a reversal of programmatic progress; this divergence between declining incidence and persistent, ageing prevalence is the central epidemiological finding of this study. Targeted interventions, including age-responsive antenatal protocols and strengthened PMTCT retention, alongside more careful consideration of expanded pre-exposure prophylaxis (PrEP) access, are needed to achieve elimination of mother-to-child transmission.

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