Impact of Antiretroviral Therapy on Incidence of Pregnancy among HIV-Infected Women in Sub-Saharan Africa: A Cohort Study

PLoS Medicine, Feb 2010

A multicountry cohort study in sub-Saharan Africa by Landon Myer and colleagues reveals higher pregnancy rates in HIV-infected women on antiretroviral therapy (ART).

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Impact of Antiretroviral Therapy on Incidence of Pregnancy among HIV-Infected Women in Sub-Saharan Africa: A Cohort Study

et al. (2010) Impact of Antiretroviral Therapy on Incidence of Pregnancy among HIV-Infected Women in Sub-Saharan Africa: A Cohort Study. PLoS Med 7(2): e1000229. doi:10.1371/journal.pmed.1000229 Impact of Antiretroviral Therapy on Incidence of Pregnancy among HIV-Infected Women in Sub-Saharan Africa: A Cohort Study Landon Myer 0 1 Rosalind J. Carter 0 1 Monica Katyal 0 1 Patricia Toro 0 1 Wafaa M. El-Sadr 0 1 Elaine J. Abrams 0 1 Lynne Mofenson, National Institute of Child Health and Human Development, United States of America 0 1 Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town , Cape Town , South Africa , 2 International Center for AIDS Care and Treatment Programs, Columbia University Mailman School of Public Health , New York , United States of America 1 Participating MTCT-Plus programs are: Formation Sanitaire Urbaine de Yopougon-Attie , Abidjan , Cote d'Ivoire; Nyanza Provincial General Hospital , Kisumu , Kenya; Moi Hospital/Mosoriot Rural Health Center , Eldoret , Kenya; Treatment and Research AIDS Center/Kigali Health Centres , Kigali , Rwanda; Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital , Soweto , South Africa; Langa Clinic, City of Cape Town Health Department , Cape Town , South Africa; Ekuphileni Clinic/ Cato Manor, University of KwaZulu-Natal , Durban , South Africa; Mulago Hospital , Kampala , Uganda; St. Francis Nsambya Hospital , Kampala , Uganda; Chelstone and Mtendere District Health Clinics , Lusaka , Zambia Background: With the rapid expansion of antiretroviral therapy (ART) services in sub-Saharan Africa there is growing recognition of the importance of fertility and childbearing among HIV-infected women. However there are few data on whether ART initiation influences pregnancy rates. Methods and Findings: We analyzed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multicountry HIV care and treatment program for women, children, and families. From 11 programs in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals; ART was initiated according to national guidelines on the basis of immunological and/or clinical criteria. Standardized forms were used to collect sociodemographic and clinical data, including incident pregnancies. Overall 589 incident pregnancies were observed among the 4,531 women included in this analysis (pregnancy incidence, 7.8/100 person-years [PY]). The rate of new pregnancies was significantly higher among women receiving ART (9.0/100 PY) compared to women not on ART (6.5/100 PY) (adjusted hazard ratio, 1.74; 95% confidence interval, 1.19-2.54). Other factors independently associated with increased risk of incident pregnancy included younger age, lower educational attainment, being married or cohabiting, having a male partner enrolled into the program, failure to use nonbarrier contraception, and higher CD4 cell counts. Conclusions: ART use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioral or biomedical mechanisms that may underlie this association require further investigation, these data highlight the importance of pregnancy planning and management as a critical but neglected component of HIV care and treatment services. Please see later in the article for the Editors' Summary. - Funding: The MTCT-Plus Initiative is funded through grants from the following philanthropic foundations: Bill & Melinda Gates Foundation, William and Flora Hewlett Foundation, David and Lucile Packard Foundation, Robert Wood Johnson Foundation, Henry J. Kaiser Family Foundation, John D. and Catherine T. MacArthur Foundation, Rockefeller Foundation, and Starr Foundation. Additional support is provided by the United States Agency for International Development. The funding agencies played no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; and the preparation, review, or approval of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Abbreviations: ART, antiretroviral therapy; CI, confidence interval; HR, hazard ratio; IQR, interquartile range; PMTCT, prevention of mother-to-child transmission; PY, person-year; RR, rate ratio Introduction By the end of 2007 there were almost 3,000,000 HIV-infected individuals receiving antiretroviral therapy (ART) in resourcelimited settings [1]. The global roll-out of ART has contributed to a greater awareness of issues related to fertility and childbearing among HIV-infected women and men [2,3], particularly in subSaharan Africa where a large proportion of HIV-infected individuals are women in their reproductive years and the prevention of mother-to-child transmission (PMTCT) of HIV is an ongoing challenge [1,4]. Studies from Europe and North America indicate that HIVinfect (...truncated)


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Landon Myer, Rosalind J. Carter, Monica Katyal, Patricia Toro, Wafaa M. El-Sadr, Elaine J. Abrams. Impact of Antiretroviral Therapy on Incidence of Pregnancy among HIV-Infected Women in Sub-Saharan Africa: A Cohort Study, PLoS Medicine, 2010, 2, DOI: 10.1371/journal.pmed.1000229