Reproductive Health

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

Myer L, Carter RJ, Katyal M, Toro P, El-Sadr WM, Abrams EJ. PLoS Med. 2010;7:e1000229.

With the rapid expansion of antiretroviral therapy 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 antiretroviral therapy initiation influences pregnancy rates. The authors analyzed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multicountry HIV care and treatment programme for women, children, and families. From 11 programmes in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals; antiretroviral therapy 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 antiretroviral therapy (9.0/100 PY) compared to women not on antiretroviral therapy (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. Antiretroviral therapy use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioural 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.

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http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000229 [2]
Editors’ note:  Although the incidence of pregnancy ranged 5-fold across these seven countries, the association between antiretroviral therapy and pregnancy was consistent across countries. Within 4 years of starting on treatment, one-third of women became pregnant, constituting an almost 80% increased incidence over women who were not yet eligible for antiretroviral therapy. There is no doubt that antiretroviral therapy can improve well-being, increase sexual activity, and lead to renewed fertility intentions through increased hope and planning for the future. However, 30% of pregnancies in sub-Saharan Africa, regardless of HIV status, are unintentional. This multi-country, women-centred, family-focused care and treatment initiative surprisingly did not include standardised counselling on pregnancy and contraceptive use, although barrier and non-barrier contraceptive methods were provided on site or by referral, and did not explore fertility desires and pregnancy plans. As a result, options for fertility planning were not systematically discussed with women, treatment regimens were not adjusted to reduce the impact of nevirapine on hormonal contraceptive blood levels for those women who chose this method of contraception, and the opportunity to help women shape their own futures and that of their families appears to have been missed. This study provides strong justification for the integration of family planning services into antiretroviral therapy programmes.
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