The next generation: Pregnancy in adolescents and women living with perinatally acquired HIV in South Africa.

Abstract

An increasing number of girls living with perinatally acquired HIV (PHIV) are reaching adolescence and adulthood andbecoming pregnant. Youth living with PHIV (YLPHIV) may have HIV-associated infections/complications, long-term exposure toantiretroviral treatment (ART), drug resistance and increased psychosocial challenges, which may adversely affect pregnancy outcomes.There is a lack of published studies on pregnancy in YLPHIV in sub-Saharan Africa.Objectives. To describe characteristics of pregnant South African (SA) YLPHIV and their pregnancy outcomes. We retrospectively identified pregnancies in YLPHIV, who were diagnosed with HIV when they were <12 years old and beforetheir first pregnancy (as a proxy for perinatal route of infection), from routinely collected data in Western Cape Province, SA (2007 - 2018).We combined these with pregnancies from a Johannesburg cohort of YLPHIV.Results. We identified 258 pregnancies among 232 females living with likely PHIV; 38.8% of pregnancies occurred in YLPHIV ≤16 yearsold, 39.1% at age 17 - 19 years and 22.1% at age ≥20 years. In recent years, a steady increase in the number of pregnancies in YLPHIV wasnoted; more than two-thirds occurred during 2016 - 2018. ART was commenced prior to pregnancy in 84.9% of YLPHIV, during pregnancyin 6.6% and was not commenced by pregnancy end date in 8.5%. Of the pregnancies in young women with documented outcomes (88.8%;n=229), 80.3% were live births, 14.4% terminations, 3.1% miscarriages and 2.2% stillbirths. Mother-to-child transmission of HIV occurredin 2.2% of infants, 75.3% were uninfected when last tested and 22.6% had unknown HIV status. Among YLPHIV with CD4 counts availablewithin 12 months of pregnancy end date (n=202), 20.3% had a CD4 count <200 cells/μL, 43.1% CD4 count 200 - 499 cells/μL and 36.6%CD4 count ≥500 cells/μL. Among those with a viral load (VL) available within 12 months of pregnancy end date (n=219), 66.7% had aVL <400 copies/mL, 5.0% VL 400 - 999 copies/mL and 28.3% VL ≥1 000 copies/mL. Of 186 neonates, 20.4% were preterm deliveries(<37 weeks' gestation). Among neonates with known birthweight (n=176), the mean birthweight was 2 900 g (95% confidence interval(CI) 2 747 - 2 935 g) and 20.5% had a low birthweight (<2 500 g). One congenital malformation (musculoskeletal) and 2 neonatal deaths were recorded. In recent years, the number of pregnancies in YLPHIV has increased. A considerable proportion of pregnancies occurred inYLPHIV ≤16 years old. A high proportion of pregnancies was electively terminated. The prevalence of elevated VL and poor immunologicalstatus among pregnant YLPHIV is concerning.