Incident Pregnancy and Time to Death or AIDS among HIV-Positive Women Receiving Antiretroviral Therapy

Daniel Westreich,Ian Sanne,Cindy Firnhaber,Pappie Majuba,Mhairi Maskew,Denise Evans

doi:10.1371/journal.pone.0058117

Abstract

BackgroundLittle is known about the impact of pregnancy on response to highly active antiretroviral therapy (HAART) in sub-Saharan Africa. We examined the effect of incident pregnancy after HAART initiation on clinical response to HAART.MethodsWe evaluated a prospective clinical cohort of adult women initiating HAART in Johannesburg, South Africa between 1 April 2004 and 31 March 2011, and followed up until an event, transfer, drop-out, or administrative end of follow-up on 30 September 2011. Women over age 45 and women who were pregnant at HAART initiation were excluded from the study. Main exposure was having experienced pregnancy after HAART initiation; main outcome was death and (separately) death or new AIDS event. We calculated adjusted hazard ratios (HRs) and 95% confidence limits (CL) using marginal structural Cox proportional hazards models.ResultsThe study included 7,534 women, and 20,813 person-years of follow-up; 918 women had at least one recognized pregnancy during follow-up. For death alone, the weighted (adjusted) HR was 0.84 (95% CL 0.44, 1.60). Sensitivity analyses confirmed main results, and results were similar for analysis of death or new AIDS event. Incident pregnancy was associated with a substantially reduced hazard of drop-out (HR = 0.62, 95% CL 0.51, 0.75).ConclusionsRecognized incident pregnancy after HAART initiation was not associated with increases in hazard of clinical events, but was associated with a decreased hazard of drop-out. High rates of pregnancy after initiation of HAART may point to a need to better integrate family planning services into clinical care for HIV-infected women.

Highlights

The majority of individuals living with HIV in sub-Saharan Africa are women, most of whom are of reproductive age. [1] In South Africa, where one-sixth of all HIV-infected individuals in the world live, HIV is common among young women and most especially young pregnant women [2,3] among whom prevalence was estimated at nearly 30% nationally in 2008 [4]
We estimated previously that of women ages 18–25 initiating highly active antiretroviral therapy (HAART), 44% would have an incident pregnancy within four years [11], while a recent study by Myer et al estimated that use of HAART was associated with a 70% higher rate of pregnancy [8]
We previously found that incident pregnancy is associated with increased risk of virologic failure in South Africa [11], but have been able to identify only a single study from Africa addressing the impact of pregnancy on mortality

Summary

Introduction

The majority of individuals living with HIV in sub-Saharan Africa are women, most of whom are of reproductive age. [1] In South Africa, where one-sixth of all HIV-infected individuals in the world live, HIV is common among young women and most especially young pregnant women [2,3] among whom prevalence was estimated at nearly 30% nationally in 2008 [4]. We previously found that incident pregnancy is associated with increased risk of virologic failure in South Africa [11], but have been able to identify only a single study from Africa addressing the impact of pregnancy on mortality. This South Africa study found no association between pregnancy prevalent at the time of HAART initiation and subsequent mortality rate over three years [27]. We examined the effect of incident pregnancy after HAART initiation on clinical response to HAART

Methods

Results

Conclusion