Pregnancies before and after HIV diagnosis in a european cohort of HIV-infected women. European Study on the Natural History of HIV Infection in Women

Induced abortion incidence and associated factors in a cohort of women living with HIV in Rio De Janeiro, Brazil, 1996-2016

BACKGROUND

Abortion is a public health problem in Latin America and is more common among women living with HIV.

OBJECTIVE

to verify the incidence and factors associated with induced abortion in a cohort of women living with HIV assisted in a reference service for care for individuals with HIV/AIDS in Rio de Janeiro/Brazil.

METHODS

Prospective cohort during the period 1996-2016. We estimated the incidence of induced abortions during follow-up in the cohort by calculating person-time incidence rates [per 100 persons-years (PY)] and investigated the factors associated with the outcome "induced abortion" using a generalized linear mixed model.

RESULTS

753 women and 210 pregnancies were included in the present analysis. We estimated an induced abortion incidence rate of 0.68/100 persons-years (95% confidence interval [CI]: 0.47; 0.94) in the study period, with a significant reduction after 2006. The main factors associated with an induced abortion were currently living with a partner (adjusted OR [AdjOR] 0.32 95% CI: 0.10-0.98), number of children (2 children AdjOR 0.12, 95% CI: 0.02-0.95) and the type of antiretroviral treatment used (regimen without Efavirenz: AdjOR: 0.11, 95% CI 0.02-0.70).

CONCLUSIONS

We showed a significant reduction in the incidence of induced abortions in a cohort of women living with HIV in Rio de Janeiro, Brazil, probably due to a decrease in the incidence of pregnancies observed in the same period. The factors associated with a lower occurrence of induced abortion suggest a good integration between the clinical and reproductive assistance offered to those women.

Pregnancy incidence, outcomes and associated factors in a cohort of women living with HIV/AIDS in Rio de Janeiro, Brazil, 1996-2016

The aim of this research was to analyze pregnancy incidence and associated factors in a cohort of 753 women living with HIV/AIDS (WLWHA) in Rio de Janeiro, Brazil, from 1996 to 2016. Women aged 18-49 years who were not on menopause (surgical or natural) and did not have a tubal ligation were eligible for the study. Data were collected by medical professionals during initial and follow-up visits. Person-time pregnancy incidence rates were calculated throughout the follow-up period. Pregnancy incidence-associated factors were investigated by univariate and multiple analyzes, using an extension of the Cox survival model. Follow-up visits recorded 194 pregnancies, with an incidence rate of 4.01/100 person-years (95% CI: 3.47; 4.60). A higher pregnancy incidence was associated with CD4 nadir ≥ 350 cells/mm³, use of an antiretroviral regimen not containing Efavirenz, and prior teenage pregnancy. In turn, women with a viral load ≥ 50 copies/mL, age ≥ 35 years old, with two or more children and using a highly effective contraceptive method showed a lower incidence. Results showed a significant reduction in pregnancy incidence after 2006, a significant reduction in female sterilization from 1996 to 2016, and a high rate of cesarean sections. The association found between pregnancy incidence and the use of contraceptive methods and virological control markers suggests a good integration between HIV/AIDS and reproductive health services. The high rate of cesarean section delivery indicates the need to improve childbirth care.

Induced abortions of women living with HIV in Finland 1987-2019: a national register study

BACKGROUND

Recent data on the rate and risk factors of induced abortion among women living with HIV (WLWH) are limited. Our aim was to use Finnish national health register data to 1) determine the nationwide rate of induced abortions of WLWH in Finland during 1987-2019, 2) compare the rates of induced abortions before and after HIV diagnosis over different time periods, 3) determine the factors associated with terminating a pregnancy after HIV diagnosis, and 4) estimate the prevalence of undiagnosed HIV at induced abortions to see whether routine testing should be implemented.

METHODS

A retrospective nationwide register study of all WLWH in Finland 1987-2019 (n = 1017). Data from several registers were combined to identify all induced abortions and deliveries of WLWH before and after HIV diagnosis. Factors associated with terminating a pregnancy were assessed with predictive multivariable logistic regression models. The prevalence of undiagnosed HIV at induced abortion was estimated by comparing the induced abortions among WLWH before HIV diagnosis to the number of induced abortions in Finland.

RESULTS

Rate of induced abortions among WLWH decreased from 42.8 to 14.7 abortions/1000 follow-up years from 1987-1997 to 2009-2019, more prominently in abortions after HIV diagnosis. After 1997 being diagnosed with HIV was not associated with an increased risk of terminating a pregnancy. Factors associated with induced abortion in pregnancies that began after HIV diagnosis 1998-2019 were being foreign-born (OR 3.09, 95% CI 1.55-6.19), younger age (OR 0.95 per year, 95% CI 0.90-1.00), previous induced abortions (OR 3.36, 95% CI 1.80-6.28), and previous deliveries (OR 2.13, 95% CI 1.08-4.21). Estimated prevalence of undiagnosed HIV at induced abortion was 0.008-0.029%.

CONCLUSIONS

Rate of induced abortions among WLWH has decreased. Family planning should be discussed at every follow-up appointment. Routine testing of HIV at all induced abortions is not cost-effective in Finland due to low prevalence.

Adverse birth outcome and associated factors among mothers with HIV who gave birth in northwest Amhara region referral hospitals, northwest Ethiopia, 2020

Adverse birth outcomes are a common cause of health problems in developing nations and have a significant negative impact on infant health as well as financial costs to families, communities, and the world. Mothers with HIV may be at increased risk of adverse birth outcomes. However, there is a limited study about adverse birth outcomes among mothers with HIV around the world including in Ethiopia. Therefore this study aimed to assess adverse birth outcomes and associated factors among mothers with HIV Facility based cross-sectional study was conducted among mothers with HIV who gave birth in northwest Amhara region referral hospitals from September 2016 to September 2019. Simple random sampling was used to select 590 mothers. Bivariable and multivariable logistic regressions were carried out to identify factors. Statistical significance was declared by using a p-value < 0.05. An adjusted odds ratio was used to show the magnitude of the association. Out of a total of 590 mothers, the prevalence of adverse birth outcomes among HIV-positive mothers was 21% (95% CI 17.8-24.6%). History of spontaneous abortion [AOR = 1.9, 95% CI (1.19, 3.70)], PROM [AOR = 3.55, 95% CI (1.72, 7.30)], opportunistic infection [AOR = 3.38, 95% CI (1.50, 8.22)], pre-pregnancy BMI of < 18.5 [AOR = 5.61, 95% CI (1.97, 15.91)], MUAC < 23 cm [AOR = 2.56, 95% CI (1.10, 5.97)], and ANC visit of < 4 times [AOR = 3.85, 95% CI (2.34, 6.55)] were significantly associated with Adverse birth outcome. The prevalence of adverse birth outcomes was high. Abortion history, MUAC, BMI, Opportunistic infection, PROM, and a number of ANC visits were associated with adverse birth outcomes. This study suggests to increase number of antenatal care follow-ups, prevent and treat opportunistic infections, and focus on early detection and treatment of pregnancy-related complication.

HIV testing in termination of pregnancy and colposcopy services: a scoping review

Background

Women and girls are relatively under-represented across the HIV treatment cascade. Two conditions unique to women, pregnancy and cervical cancer/dysplasia, share a common acquisition mode with HIV. This scoping review aimed to explore HIV testing practices in voluntary termination of pregnancy (TOP) and colposcopy services.

Methods

The scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We searched articles published up to 20 December 2020 using three electronic databases (PubMed/Medline, Embase, Google Scholar) and including the keywords “HIV Testing”, “Abortion, Induced”, “Colposcopy”, “HIV screen*” and “termination of pregnancy”.

Results

A total of 1496 articles were identified, of which 55 met the inclusion criteria. We included studies providing background HIV prevalence in addition to prevalence in the study population and studies of women seeking TOP rather than presenting with TOP complications. This limited our review to high-income, low HIV prevalence settings. We observed two study phases: studies pre-antiretroviral therapy (ART) using unlinked anonymous testing data and examining HIV risk factors associated with positive HIV tests and studies post-ART using routine testing data and exploring HIV testing uptake. HIV prevalence was estimated at >0.2% in most TOP settings and >1% (range 1.7%–11.4%) in colposcopy services. Many TOP providers did not have local HIV testing policies and HIV testing was not mentioned in many specialist guidelines. Testing uptake was 49%–96% in TOP and 23%–75% in colposcopy services.

Conclusion

Given the estimated HIV prevalence of >0.1% among women attending TOP and colposcopy services, HIV testing would be economically feasible to perform in high-income settings. Explicit testing policies are frequently lacking in these two settings, both at the local level and in specialist guidelines. Offering HIV testing regardless of risk factors could normalise testing, reduce late HIV presentation and create an opportunity for preventive counselling.

Prevalence and factors associated with fertility desire among people living with HIV: A systematic review and meta-analysis

BACKGROUND

The fertility desire of people living with HIV (PLHIV) has been rising in the past decade. However, there are many studies among which the association remains controversial between the fertility desire of HIV-infected persons and antiretroviral therapy (ART), sex, marital status, and educational level.

METHODS

We performed a literature search of these meta-analyses in PubMed, the Cochrane Library, Web of Science and ScienceDirect in November 2019. We also reviewed references of eligible studies to complement the search. We used pooled odds ratios (ORs) and 95% confidence intervals (CIs) with a random-effects model and a fixed-effects model to estimate the association between fertility desire among PLHIV and ART, sex, age, marital status, educational level, and number of children. Subgroups with I square values (I2) and sensitivity analyses were performed to assess the heterogeneity and the stability of the overall ORs, respectively. We evaluated publication bias using Egger's test and a visual inspection of the symmetry in funnel plots.

RESULTS

In these meta-analyses 50 articles were included with 22,367 subjects. The pooled prevalence of fertility desire among PLHIV was estimated to be 42.04%. The pooled analyses showed that the fertility desire of PLHIV is associated with ART (OR = 1.11, 95% CI:1.00-1.23, P = 0.043), sex (OR = 1.51, 95% CI:1.10-2.09), age (OR = 2.65, 95% CI:2.24-3.14), marital status (OR = 1.34, 95% CI:1.08-1.66), educational level (OR = 0.85, 95% CI:0.73-1.00, P = 0.047) and the number of children (OR = 3.99, 95% CI:3.06-5.20). PLHIV who are on ART, are male, are younger than 30, are married/cohabiting, have received a secondary education or above, and are childless have a higher prevalence of fertility desire. The two factors of age and the number of children, in particular demonstrated a strong significant association with fertility desire. We found moderate heterogeneity in the meta-analyses of age and educational level and high heterogeneity in the meta-analyses of sex, marital status and number of children. Publication bias was detected in the meta-analyses of the association of fertility with sex and educational level.

CONCLUSION

This study demonstrates that the prevalence of fertility desire among HIV-infected people is 42.04%, and the fertility desire among PLHIV is associated with ART experience, sex, age, marital status, the number of children, and educational level. Since a majority of PLHIV are of reproductive age, it is necessary to support PLHIV in terms of their needs regarding reproductive decision-making. Through counseling and reproductive health care, further measures to prevent the horizontal and vertical transmission of HIV should be taken.

Prevalence of induced abortion and associated factors in a cohort of women living with HIV/AIDS, Rio de Janeiro, Brazil, 1996-2016

The aim of this study was to verify the prevalence of induced abortion and associated factors at the time of inclusion in a cohort of women living with HIV/AIDS in the city of Rio de Janeiro, Brazil, from 1996 to 2016. Eligibility criteria for inclusion in the cohort were female sex at birth, age 18 years and older, and confirmed HIV infection. At the baseline visit, data on sexual, reproductive, and behavioral aspects and HIV infection were obtained through a face-to-face interview with the attending physician. Lifetime prevalence of induced abortion was calculated, and factors associated with induced abortion were verified by multiple logistic regression for all the women and for those with previous pregnancy. In the entire cohort of women, 30.4% reported a history of induced abortion, compared to 33.5% in women with previous pregnancy. Frequency of reported induced abortion showed a significant reduction during the period (41.7% in 1996-2000 versus 22.5% in 2011-2016, p < 0.001). Factors associated with induced abortion, both for the entire cohort and for the women with previous pregnancy, were age, schooling, ≥ 5 lifetime sexual partners, teenage pregnancy, lifetime use of any illicit drug, and inclusion in the cohort after the year 2005. Changes in the socioeconomic, sexual, reproductive, and HIV infection profile are possible explanations for the reduction in abortions during the period. Studies that use direct methods to measure abortion should be conducted in other populations to confirm the downward trend in induced abortion and its determinants in Brazil.

Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare

This quantitative study in the city of São Paulo, Brazil, compared contexts of social vulnerability and sexual and reproductive behavior in a sample of 975 women living with HIV/AIDS (WLHIV) and 1,003 women not living with HIV, the latter recruited among users of the primary healthcare system. WLHIV experienced situations of greater vulnerability that potentially increased their risk of HIV infection and unplanned pregnancy and abortion. Compared to women users of the primary healthcare system, WLHIV reported higher rates of drug use, sex for money, exposure to intimate partner violence, difficulties in access to services for prevention and early diagnosis, unplanned pregnancies, induced abortion, and teenage pregnancy. A considerable number of the women users of the primary healthcare system shared these same experiences, but at lower rates. The identification of contexts of vulnerability and the integration of HIV testing services with sexual and reproductive health services should constitute lines of care for these women, both in specialized and primary care services.

Pregnancy incidence and intention after HIV diagnosis among women living with HIV in Canada

BACKGROUND

Pregnancy incidence rates among women living with HIV (WLWH) have increased over time due to longer life expectancy, improved health status, and improved access to and HIV prevention benefits of combination antiretroviral therapy (cART). However, it is unclear whether intended or unintended pregnancies are contributing to observed increases.

METHODS

We analyzed retrospective data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Kaplan-Meier methods and GEE Poisson models were used to measure cumulative incidence and incidence rate of pregnancy after HIV diagnosis overall, and by pregnancy intention. We used multivariable logistic regression models to examine independent correlates of unintended pregnancy among the most recent/current pregnancy.

RESULTS

Of 1,165 WLWH included in this analysis, 278 (23.9%) women reported 492 pregnancies after HIV diagnosis, 60.8% of which were unintended. Unintended pregnancy incidence (24.6 per 1,000 Women-Years (WYs); 95% CI: 21.0, 28.7) was higher than intended pregnancy incidence (16.6 per 1,000 WYs; 95% CI: 13.8, 20.1) (Rate Ratio: 1.5, 95% CI: 1.2-1.8). Pregnancy incidence among WLWH who initiated cART before or during pregnancy (29.1 per 1000 WYs with 95% CI: 25.1, 33.8) was higher than among WLWH not on cART during pregnancy (11.9 per 1000 WYs; 95% CI: 9.5, 14.9) (Rate Ratio: 2.4, 95% CI: 2.0-3.0). Women with current or recent unintended pregnancy (vs. intended pregnancy) had higher adjusted odds of being single (AOR: 1.94; 95% CI: 1.10, 3.42), younger at time of conception (AOR: 0.95 per year increase, 95% CI: 0.90, 0.99), and being born in Canada (AOR: 2.76, 95% CI: 1.55, 4.92).

CONCLUSION

Nearly one-quarter of women reported pregnancy after HIV diagnosis, with 61% of all pregnancies reported as unintended. Integrated HIV and reproductive health care programming is required to better support WLWH to optimize pregnancy planning and outcomes and to prevent unintended pregnancy.

Post-diagnosis abortion in women living with HIV/Aids in the south of Brazil

OBJECTIVE

To understand how the HIV diagnosis combines with other factors that influence the decision to abort.

METHODOLOGY

Data were collected during a crossover study of women aged between 18 and 49 years old and seen in public health services in Porto Alegre, Brazil. The life stories of 18 interviewees who had post-diagnosis abortion were reconstructed on a timeline, using information collected quantitatively.

RESULTS

The time between the diagnosis and abortion was 2 years or less for more than half of the women. For some, post-diagnosis abortion did not mean the end of reproductive life. The most frequent reason for terminating pregnancy was to be living with HIV; however, only some of the women who stated having this motivation did not have post-diagnosis children. Changing partners between pregnancies was a recurring finding; however, in most pregnancies that ended in abortion, the women lived with their partners.

DISCUSSION

The analysis of the reproductive trajectory of the women studied showed that there is no specific profile of the woman who aborts after receiving the HIV diagnosis. Although this diagnosis may be involved in the decision to terminate a pregnancy, it does not necessarily result in the end of a woman's reproductive trajectory. Thus, abortion should be understood within a diversity of decision-making processes and the specific moment of a woman's life story.

Reproductive history before and after HIV diagnosis: A cross-sectional study in HIV-positive women in Spain

The aim of this study is to examine the reproductive history of human immunodeficiency virus (HIV)-positive women, before and after HIV diagnosis, to describe the characteristics of women with pregnancies after HIV diagnosis, and to assess the prevalence of mother-to-child transmission.A cross-sectional study was performed among women within reproductive ages (18-49) selected from the cohort in the Spanish AIDS Research Network (CoRIS). A descriptive analysis of the pregnancy outcomes was made according to women's serostatus at the moment of pregnancy and association of women's characteristics with having pregnancy after HIV diagnosis was evaluated using logistic regression models.Overall, 161 women were interviewed; of them, 86% had been pregnant at least once and 39% after HIV diagnosis. There were 347 pregnancies, 29% of them occurred after HIV diagnosis and in these, 20% were miscarriages and 29% were voluntary termination of pregnancy. There were 3 cases of mother-to-child transmission among the 56 children born from HIV-positive mothers; in these cases, women were diagnosed during delivery. Having a pregnancy after HIV diagnosis was more likely when the younger women were at the time of diagnosis: odds ratio (OR) = 1.29 (95% confidence interval 0.40-4.17) for 25 to 29 years old, OR = 0.59 (0.15-2.29) for 30 to 34 years old, OR = 0.14 (0.03-0.74) for ≥35 years old, compared with those <25 years at diagnosis, who were diagnosed for ≥5 years (OR = 5.27 [1.71-16.18]), who received antiretroviral treatment at some point (OR = 9.38 [1.09-80.45]), and who received information on reproductive health (OR = 4.32 [1.52-12.26]).An important number of pregnancies occurred after HIV diagnosis, reflecting a desire for motherhood in these women. Reproductive and sexual health should be tackled in medical follow-ups.

Differences in the Access to Sterilization between Women Living and Not Living with HIV: Results from the GENIH Study, Brazil

BACKGROUND

In many countries, young women of reproductive age have been especially affected by the HIV epidemic, which have fostered research to better understand how HIV infection influences and shapes women´s fertility and reproductive and sexual decisions. In Brazil, few studies have focused on the impact of the HIV epidemic on contraceptive choices among women living with HIV (WLHIV).

OBJECTIVE

This study evaluates the impact HIV infection may have in the access to female sterilization in Brazil, using a time-to-event analysis.

METHODS

A cross-sectional quantitative study (GENIH study) was conducted between February 2013 and April 2014 in the city of São Paulo, comparing two probabilistic samples of 975 WLHIV and 1,003 women not living with HIV (WNLHIV) aged 18 to 49. Sexual and reproductive data was collected retrospectively in order to reconstruct women's reproductive trajectories. Given the objectives of this study, the analysis was restricted to women with parity one or more and, in case of WLHIV, to those sterilized after HIV diagnosis and not infected through vertical transmission. The final sample analysis included 683 WNLHIV and 690 WLHIV. A series of multivariable-adjusted Cox models estimated the probability of being sterilized after HIV diagnosis, compared with WNLHIV. Models were adjusted for schooling, race/color, and stratified by parity at last delivery (1-2, 3+). Hazard ratios were calculated for female sterilization, and separately for interval and postpartum procedures (performed in conjunction with caesarean section or immediately after vaginal delivery). Additionally, information regarding unmet demand for female sterilization was also explored.

FINDINGS

No statistical difference in the overall risk of sterilization between WLHIV and WNLHIV in the two parity-related groups is observed: HR = 0.88 (0.54-1.43) and 0.94 (0.69-1.29), respectively, among women with 1-2 children and those with three and more. However, significant differences regarding the impact of HIV infection at sterilization are observed depending on the timing and the type of sterilization procedure. The probability of obtaining an interval sterilization is significantly lower for WLHIV compared to those not living with HIV. The reverse occurs regarding postpartum sterilization. Although sterilization is mainly performed in conjunction with caesarean section in Brazil, it is evident that caesarean sections are not the sole factor increasing the risk of sterilization among WLHIV.

CONCLUSION

The results indicate barriers in the access to services offering interval sterilization for WLHIV and certain facilitation in obtaining the procedure in conjunction with caesarean section. Health policy makers at local and national levels should promote institutional changes in order to facilitate access to interval sterilization and to confront the sensitive discussion of WLHIV's eligibility for postpartum sterilization. It is also urgent to increase access to a wider range of contraceptive methods for WLHIV and promote dual method protection strategies. Moreover, since condom use may decrease in the future in the context of the preventive effect of antiretroviral therapy, promoting dual methods will expand the choices regarding the reproductive rights of women living with HIV.

Lifetime induced abortion: a comparison between women living and not living with HIV

Background

Studies aimed at understanding the association between induced abortion and HIV are scarce and differ on the direction of the association. This paper aims to show the prevalence of induced abortion in a sample of pregnancies of women living and not living with HIV/Aids, determining variables associated with pregnancy termination and linked to the life course of women and to the specific context of the pregnancy.

Methods

Data came from a cross-sectional study, using interviewer-administered questionnaire, developed with women that attended public health services in Porto Alegre, Brazil. A generalized estimating equation model with logit link measured the association between determinants and abortion.

Findings

The final sample was composed of 684 women living with HIV/Aids (2,039 pregnancies) and 639 women not living with HIV/Aids (1,539 pregnancies). The prevalence of induced abortion among pregnancies in women living with HIV/Aids was 6.5%, while in women not living with HIV/Aids was 2.9%. Among women living with HIV/Aids, the following were associated with induced abortion in the multivariable analysis: being older, having a higher education level, having had more sexual partners (i.e., variables linked to the life course of women), having had children prior to the index pregnancy and living with a sexual partner during pregnancy (i.e., variables linked to the context of each pregnancy). On the other hand, among women not living with HIV/Aids, only having a higher education level and having had more sexual partners (i.e., determinants linked to the life course of women) were associated with voluntary pregnancy termination in multivariable analysis.

Conclusion

Although determinants are similar between women living and not living with HIV/Aids, prevalence of induced abortion is higher among pregnancies in women living with HIV/Aids, pointing to their greater social vulnerability and to the need for public policy to address prevention and treatment of HIV associated with reproductive issues.

Contemplating abortion: HIV-positive women's decision to terminate pregnancy

Research on pregnancy termination largely assumes HIV status is the only reason why HIV-positive women contemplate abortion. As antiretroviral treatment (ART) becomes increasingly available and women are living longer, healthier lives, the time has come to consider the influence of other factors on HIV-positive women's reproductive decision-making. Because ART has been free and universally available to Brazilians for more than two decades, Brazil provides a unique context in which to explore these issues. A total of 25 semi-structured interviews exploring women's pregnancy termination decision-making were conducted with women receiving care at the Reference Centre for HIV/AIDS in Salvador, Brazil. Interviews were transcribed, translated into English and coded for analysis. HIV played different roles in women's decision-making. In all, 13 HIV-positive women did not consider terminating their pregnancy. Influential factors described by those who did consider terminating their pregnancy included fear of HIV transmission, fear of HIV-related stigma, family size, economic constraints, partner and provider influence, as well as lack of access to pregnancy termination services and abortifacients. For some HIV-positive women in Brazil, HIV can be the only reason to consider terminating a pregnancy, but other factors are significant. A thorough understanding of all variables affecting reproductive decision-making is necessary for enhancing services and policies and better meeting the needs and rights of HIV-positive women.

Incidence and predictors of pregnancy among a cohort of HIV-positive women initiating antiretroviral therapy in Mbarara, Uganda

Objective

Many people living with HIV in sub-Saharan Africa desire biological children. Implementation of HIV prevention strategies that support the reproductive goals of people living with HIV while minimizing HIV transmission risk to sexual partners and future children requires a comprehensive understanding of pregnancy in this population. We analyzed prospective cohort data to determine pregnancy incidence and predictors among HIV-positive women initiating antiretroviral therapy (ART) in a setting with high HIV prevalence and fertility.

Methods

Participants were enrolled in the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort of HIV-positive individuals initiating ART in Mbarara. Bloodwork (including CD4 cells/mm³, HIV viral load) and questionnaires (including socio-demographics, health status, sexual behavior, partner dynamics, HIV history, and self-reported pregnancy) were completed at baseline and quarterly. Our analysis includes 351 HIV-positive women (18–49 years) who enrolled between 2005–2011. We measured pregnancy incidence by proximal and distal time relative to ART initiation and used multivariable Cox proportional hazards regression analysis (with repeated events) to identify baseline and time-dependent predictors of pregnancy post-ART initiation.

Results

At baseline (pre-ART initiation), median age was 33 years [IQR: 27–37] and median prior livebirths was four [IQR: 2–6]. 38% were married with 61% reporting HIV-positive spouses. 73% of women had disclosed HIV status to a primary sexual partner. Median baseline CD4 was 137 cells/mm³ [IQR: 81–207]. At enrolment, 9.1% (31/342) reported current pregnancy. After ART initiation, 84 women experienced 105 pregnancies over 3.8 median years of follow-up, yielding a pregnancy incidence of 9.40 per 100 WYs. Three years post-ART initiation, cumulative probability of at least one pregnancy was 28% and independently associated with younger age (Adjusted Hazard Ratio (AHR): 0.89/year increase; 95%CI: 0.86–0.92) and HIV serostatus disclosure to primary sexual partner (AHR: 2.45; 95%CI: 1.29–4.63).

Conclusions

Nearly one-third of women became pregnant within three years of initiating ART, highlighting the need for integrated services to prevent unintended pregnancies and reduce periconception-related risks for HIV-infected women choosing to conceive. Association with younger age and disclosure suggests a role for early and couples-based safer conception counselling.

Bolstering the Evidence Base for Integrating Abortion and HIV Care: A Literature Review

HIV-positive women have abortions at similar rates to their HIV-negative counterparts, yet little is known about clinical outcomes of abortion for HIV-positive women or the best practices for abortion provision. To fill that gap, we conducted a literature review of clinical outcomes of surgical and medication abortion among HIV-positive women. We identified three studies on clinical outcomes of surgical abortion among HIV-positive women; none showed significant differences in infectious complications by HIV status. A review of seven articles on similar gynecological procedures found no differences in complications by HIV status. No studies evaluated medication abortion among HIV-positive women. However, we did find that previously expressed concerns regarding blood loss and vomiting related to medication abortion for HIV-positive women are unwarranted based on our review of data showing that significant blood loss and vomiting are rare and short lived among women. We conclude that although there is limited research that addresses clinical outcomes of abortion for HIV-positive women, existing data suggest that medication and surgical abortion are safe and appropriate. Sexual and reproductive health and HIV integration efforts must include both options to prevent maternal mortality and morbidity and to ensure that HIV-positive women and women at risk of HIV can make informed reproductive decisions.

Fertility choices and management for HIV-positive women

PURPOSE OF REVIEW

It is becoming increasingly important to address the issue of reproductive counselling and management of HIV-infected individuals during their reproductive years. Sexual and reproductive health-related needs and aspirations are similar to those of uninfected individuals but some differences require specific attention, which are discussed in this review.

RECENT FINDINGS

Hormonal contraception should be used with caution in women on antiretroviral treatment. Its impact on both HIV infectivity and disease progression is still controversial. An intrauterine device can be considered for pregnancy prevention and pregnancy termination should be offered in safe conditions. HIV-infected women have a lower spontaneous fertility rate, which may persist after assisted reproduction. Data on safety of antiretroviral treatment during conception are reassuring. No clear association can be found between exposure to antiretrovirals and fetal abnormalities. Secondary prevention remains crucial and condom use remains a key method.

SUMMARY

Different topics related to fertility choices among HIV-infected patients should be addressed. Family planning methods and termination of pregnancy have specific aspects among infected individuals. When needed, medically assisted reproduction may be required and antiretroviral treatment should be adapted before conception. Secondary prevention has a key role in reducing newly acquired infections.

The changing face of HIV in pregnancy in Rhode Island 2004-2009

Meeting the needs of HIV-infected pregnant women requires understanding their backgrounds and potential barriers to care and safe pregnancy. Foreign-born women are more likely to have language, educational, and economic barriers to care, but may be even more likely to choose to keep a pregnancy. Data from HIV-infected pregnant women and their children in Rhode Island were analyzed to identify trends in demographics, viral control, terminations, miscarriages, timing of diagnosis, and adherence to followup. Between January 2004 and December 2009, 76 HIV-infected women became pregnant, with a total of 95 pregnancies. Seventy-nine percent of the women knew their HIV status prior to becoming pregnant. Fifty-four percent of the women were foreign-born and 38 percent of the 16 women who chose to terminate their pregnancies were foreign-born. While the number of HIV-infected women becoming pregnant has increased only slightly, the proportion that are foreign-born has been rising, from 41 percent between 2004 and 2005 to 57.5 percent between 2006 and 2009. A growing number of women are having multiple pregnancies after their HIV diagnosis, due to the strength of their desire for childbearing and the perception that HIV is a controllable illness that does not preclude the creation of a family.

Incidence, patterns, and predictors of repeat pregnancies among HIV-infected women in the United Kingdom and Ireland, 1990-2009

OBJECTIVE

To explore the pattern of repeat pregnancies among diagnosed HIV-infected women in the United Kingdom and Ireland, estimate the rate of these sequential pregnancies, and investigate the demographic and clinical characteristics of women experiencing them.

DESIGN

Diagnosed HIV-infected pregnant women are reported through an active confidential reporting scheme to the National Study of HIV in Pregnancy and Childhood.

METHODS

Pregnancies occurring during 1990-2009 were included. Multivariable analyses were conducted fitting Cox proportional hazards models.

RESULTS

There were 14,096 pregnancies in 10,568 women; 2737 (25.9%) had 2 or more pregnancies reported. The rate of repeat pregnancies was 6.7 (95% confidence interval: 6.5 to 7.0) per 100 woman-years. The proportion of pregnancies in women who already had at least 1 pregnancy reported increased from 20.3% (32 of 158) in 1997 to 38.6% (565 of 1465) in 2009 (P < 0.001). In multivariable analysis, the probability of repeat pregnancy significantly declined with increasing age at first pregnancy. Parity was also inversely associated with repeat pregnancy. Compared with women born in the United Kingdom or Ireland, those from Europe, Eastern Africa, and Southern Africa were less likely to have a repeat pregnancy, whereas women from Middle Africa and Western Africa were more likely to. Maternal health at first pregnancy was not associated with repeat pregnancy.

CONCLUSIONS

The number of diagnosed HIV-infected women in the United Kingdom and Ireland experiencing repeat pregnancies is increasing. Variations in the probability of repeat pregnancies, according to demographic and clinical characteristics, are an important consideration when planning reproductive health services and HIV care for people living with HIV.

Pharmacokinetic interactions between the hormonal emergency contraception, levonorgestrel (Plan B), and Efavirenz

OBJECTIVES

Compare the Plan B levonorgestrel (LNG) area under the concentration- time curve (AUC(12)) prior to and with efavirenz (EFV). Design. Prospective, open-label, single-arm, equivalence study.

METHODS

Healthy HIV-negative subjects underwent 12 hr intensive pharmacokinetic (PK) sampling following single dose LNG alone and after 14 days of EFV. Geometric means, Geometric Mean Ratios, and 90% confidence intervals (CI) are reported for PK Parameters. T-tests were utilized. Clinical parameters and liver function tests (LFTs) were assessed.

RESULTS

24 women enrolled and 21 completed the study. With EFV, LNG AUC(12) was reduced 56% (95% CI: 49%, 62%) from 42.9 to 17.8 ng∗hr/mL, and maximum concentration (C(max)) was reduced 41% (95% CI: 33%, 50%) from 8.4 to 4.6 ng/mL. LNG was well tolerated with no grade 3 or 4 treatment-related toxicities.

CONCLUSIONS

EFV significantly reduced LNG exposures. Higher LNG doses may be required with EFV. These results reinforce the importance of effective contraception in women taking EFV.

Previous antiretroviral therapy for prevention of mother-to-child transmission of HIV does not hamper the initial response to PI-based multitherapy during subsequent pregnancy

BACKGROUND

Few data are available on the possible long-term negative effects of a short exposure to antiretroviral therapy (ART) for prevention of mother-to-child transmission (PMTCT).

OBJECTIVE

To determine whether ART for PMTCT, discontinued after delivery, affects the virological response to highly active antiretroviral therapy (HAART) administered during subsequent pregnancies.

METHODS

All current pregnancies of HIV-1-infected women enrolled in the French Perinatal Cohort (ANRS CO-01 EPF) between 2005 and 2009 and not receiving ART at the time of conception were eligible. We studied the association between history of exposure to ART during a previous pregnancy and detectable viral load (VL) under multitherapy at current delivery (VL ≥ 50 copies/mL).

RESULTS

Among 1116 eligible women, 869 were ART naive and 247 had received PMTCT during a previous pregnancy. Previous ART was protease inhibitor (PI)-based HAART in 48%, non-PI-based HAART in 4%, nucleoside reverse transcriptase inhibitor bitherapy in 19% and zidovudine monotherapy in 29% of the women. At current pregnancy, women with or without prior exposure to ART had similar CD4 cell counts and VL before ART initiation. PI-based HAART was initiated in 90% of the women. VL was undetectable (<50 copies/mL) at delivery in 65% of previously ART-naive women, 72% of women previously exposed to HAART, 62% previously exposed to bitherapy, and 67% previously exposed to monotherapy for prophylaxis (P = 0.42). Detectable VL was not associated with previous exposure in multivariate analysis (adjusted OR for previous versus no previous exposure to ART: 0.92; 0.95% confidence interval: 0.59 to 1.44).

CONCLUSIONS

Efficacy of PI-based combinations is not decreased in women previously exposed to various regimens of antiretroviral PMTCT.

Pregnancy rates and predictors in women with HIV/AIDS in Rio de Janeiro, Southeastern Brazil

OBJECTIVE

To assess incidence and predictors of first pregnancy among women with HIV/AIDS.

METHODS

Prospective cohort study was conducted in Rio de Janeiro, southeastern Brazil, between 1996 and 2003. This study comprised 225 women with HIV/AIDS followed up until their first pregnancy or first censored event (hysterectomy, tubal ligation, menopause, 50 years of age, loss to follow-up, death or the end of December 2003). Pregnancy and abortion rates were estimated, and Cox proportional hazards models were used to identify baseline characteristics associated with pregnancy risk.

RESULTS

The women were followed up for 565 person/years with a median follow-up of 3 years per women. The mean age was 32 years (SD: 7), and 54.7% were white. There were 60 pregnancies in 39 women, and 18 were terminated (induced abortions), accounting for a rate of 6.9% and 2.1% women/year, respectively. Repeated pregnancies occurred in 33.3% of the women (13/39). Higher pregnancy risk was seen among younger women (HR=3.42; 95%CI: 1.69;6.95) and those living with their partners (HR=1.89; 95%CI: 1.00;3.57). Lower pregnancy risk was associated with higher education level (HR=0.43; 95%CI: 0.19;0.99) and use of antiretroviral therapy (HR=061; 95%CI: 0.31;1.17).

CONCLUSIONS

Lower pregnancy rates were found in our cohort than in the general population. Sociodemographic characteristics should be taken into consideration in the management of reproductive health in HIV-positive childbearing age women. Reproductive and family planning counseling must be incorporated into HIV/AIDS programs for women to help preventing HIV transmission to their partners and offspring.

Fertility intentions of HIV-infected women in the United Kingdom

In the United Kingdom (UK), the number of pregnancies in HIV-infected women has increased dramatically over the last decade, but attitudes towards childbearing among infected women have not been previously described. The aim of this survey was to explore fertility intentions among HIV-infected women and to assess the effect of HIV treatment and interventions for prevention of mother-to-child transmission (PMTCT) on these intentions. HIV-infected women, aged between 16 and 49 years, attending one of seven HIV clinics in the UK between July 2003 and January 2004 were asked to complete a questionnaire. Information on demographic factors, HIV test history, pregnancy history and fertility intentions (i.e., desire for children) was collected. Eighty-six per cent of eligible women (450/521) completed the questionnaire. Three quarters of women (336/450) reported that they wanted (more) children. Forty-five per cent (201/450) reported that HIV diagnosis did not affect their fertility intentions, 11% (50/450) that it made them want children sooner, and 10% (44/450) did not know or reported other views. About one third of women (155/450) decided they no longer wanted children after their HIV diagnosis, but 41% of these (59/144) had changed their mind following advances in HIV management and treatment. Factors associated with an increase in fertility intentions after advances in HIV management and treatment were being in a partnership and having fewer than two children. In this survey of HIV-infected women, the majority wanted children and women were more likely to want children after improvements in HIV management and treatment. These findings highlight the need for specialised family planning and reproductive health services targeting this population.

Fertility among HIV-infected Indian women: the biological effect and its implications

In India, nearly one million women of childbearing age are infected with HIV. This study sought to examine the biological effect of HIV on the fertility of HIV-infected Indian women. This is relevant for the provision of pregnancy-related counselling and care to the infected women, and for estimating the HIV prevalence among women and children. The study used retrospectively collected data from the National Family Health Survey (2005-2006) and applied a matched case control study design to compare the effect of HIV on conception, pregnancy rates and pregnancy outcomes among HIV-infected (N=69) and HIV-non-infected (N=345) women, both unaware of their HIV status. Pregnancy rates and pregnancy outcomes were compared through non-parametric statistical tests, whereas the effect of HIV on fecundity was studied by analysing the interval between last two pregnancies using Cox regression. The pregnancy rate was observed to be lower among HIV-infected than HIV-non-infected women (RR=0.77). The difference, however, was not statistically significant (p=0.064). There was also no statistically significant difference in the interval between last two pregnancies (p=0.898). Significantly higher number of pregnancies among HIV-infected women resulted in termination because of miscarriage or stillbirths (p=0.004). Therefore, while providing clinical care and counselling to infected women, the possibility of adverse pregnancy outcomes should be considered. Due to the higher rate of adverse pregnancy outcomes, attendance of HIV-infected women at antenatal clinics might be greater, which could lead to overestimation of HIV prevalence derived from antenatal care surveillance sites.

Voluntary pregnancy termination among women with HIV in the HAART era (2002-2008): a case series from a national study

There is limited information about the determinants of voluntary pregnancy termination (VPT) among women with HIV in the current context of wide access to highly active antiretroviral therapy (HAART). To investigate this issue, we analysed the characteristics of a series of VPTs which occurred in an ongoing observational national study of pregnant women with HIV between 2002 and 2008. Sixty-three cases of VPT were compared with 334 pregnancies not ending in a VPT concurrently reported from the same centres. VPTs showed significant associations with unplanned pregnancy (odds ratio [OR]: 24.3; 95% confidence interval [CI]: 5.8-101.2), previous pregnancies reported to the study (OR: 2.5; 95% CI: 1.30-4.82), lower CD4 counts (270 vs. 420 cells/mm(3)), and HIV-infected current partner (OR: 1.88; 95% CI: 0.97-3.63). Our data indicate that there is still the need to improve pregnancy planning among women with HIV, and strongly suggest that interventions aimed at improving pregnancy planning might also reduce the occurrence of VPT. Women with low CD4 counts and those with an HIV-infected partner represent two groups that should receive particular attention in preventive strategies.

Repeated pregnancy among women with known HIV status in Pune, India

HIV-positive women of reproductive age face challenges in decision making related to pregnancy. Understanding factors influencing repeat pregnancies in women with known HIV status are necessary to guide interventions and counseling strategies to better inform and support them. We compared three groups of women attending a large antenatal clinic in Pune, India. They include: Group A--63 HIV-positive women coming for care for a repeat pregnancy after being diagnosed in a previous pregnancy; Group B--64 HIV-negative (repeat) pregnant women attending this antenatal clinic; and Group C--63 HIV-positive non-pregnant women currently enrolled in an ongoing clinical trial. Comparisons of Group A and B indicate that the likelihood of unplanned repeat pregnancies was significantly higher in HIV-positive (70%) than HIV-negative (36%) women (OR=4.1, CI: 2.0-8.7). Inability to terminate the pregnancy (31%) and familial obligations (40%) appear to be important for continuing the unplanned repeat pregnancy. Despite high reported contraceptive use by HIV-positive women, pregnancies still occurred. Death of their youngest child is an important factor as 21% of HIV-positive pregnant women lost their youngest child compared with 3% of HIV-negative women and 3% of HIV-positive non-pregnant women (p<0.001). Repeat pregnancies were more likely to occur for women who did not disclose their HIV status to their spouse. Thus the majority of the repeat pregnancies for HIV-positive women were both unplanned and unwanted.

Effects of HIV antiretrovirals on the pharmacokinetics of hormonal contraceptives

OBJECTIVES

To review available information on pharmacokinetic effects of HIV antiretrovirals on hormonal contraceptives.

METHODS

A PubMed search was conducted from 1964 to 2006 using each antiretroviral generic name and the keywords contraceptive, contraception, ethinyl oestradiol, oestrogen, and progestin. Abstracts from the annual Conference on Retroviruses and Opportunistic Infections and International AIDS Society Conferences from 1998-2006 as well as package product inserts were reviewed for completeness.

RESULTS

Antiretroviral regimens containing protease inhibitors and non-nucleoside reverse transcriptase inhibitors may decrease the area under the curve (AUC) levels of steroids released by hormonal contraceptives. Some antiretroviral-hormonal contraceptive pairs do not decrease steroid hormone levels.

CONCLUSION

Pharmacokinetic interactions of antiretrovirals on hormonal contraceptives are specific to the type of antiretroviral and hormonal contraceptive being utilized. HIV-positive women may be counselled to use dual methods of hormonal and barrier contraception to prevent pregnancy with maximal efficacy as well as to reduce possibility of HIV transmission. Oral contraceptives might be administered with non-ritonavir boosted atazanavir or non-ritonavir boosted indinavir without a loss of contraceptive efficacy. Depot medroxyprogesterone acetate may be safe to administer with efavirenz, nevirapine, and nelfinavir. However, further studies are needed to determine the clinical relevance of the interactions between hormonal contraceptives and antiretrovirals and to explore potential dose adjustments to improve contraceptive efficacy.

Sexuality, reproduction, and HIV in women: the impact of antiretroviral therapy in elective pregnancies in Cuba

OBJECTIVE

Since HIV was first diagnosed in Cuba in 1985 to the end of 2006, 246 HIV-positive women have given birth to 266 children; of these, more than half were born after 2001, when antiretroviral therapy (ART) became widely available in Cuba. The objective of the study was to explore how the provision of ART free at point of delivery to all clinically indicated patients might be related to the rapid increase in pregnancies in HIV-positive women.

DESIGN

: A qualitative instrument was designed to assess how reproductive and sexual histories were affected by a diagnosis of HIV and by the availability of ART.

METHODS

Data were collected from 55 women, representing 26% of HIV-positive women who are known to have given birth in Cuba. A structured interview was used to collect qualitative information on women's reproductive and sexual histories.

RESULTS

Sixty-four per cent of women interviewed reported becoming pregnant aware of their HIV status or that of their partner; of these, all except one became pregnant after ART became widely available in Cuba. The majority said their worries about transmitting HIV subsided after talking to doctors, obtaining information on mother-to-child transmission, learning they could receive ART and deliver by Cesarean section to reduce the risk of vertical transmission significantly, and meeting HIV-positive women who had HIV-negative children.

CONCLUSION

The introduction of effective therapy for HIV, by transforming the social and clinical course of HIV/AIDS and allowing the possibility of having HIV-negative children, contributes to decrease HIV/AIDS-related fear and stigma and reshape reproduction.

Pregnancy rates and birth outcomes among women on efavirenz-containing highly active antiretroviral therapy in Botswana

BACKGROUND

Millions of HIV-infected women in developing countries are in need of safe and highly effective antiretroviral therapy. Pregnancy rates are usually high in developing countries, and efavirenz (EFV) use in women of childbearing age is of concern because of its potential teratogenicity.

METHODS

As part of a prospective study comparing 6 initial highly active antiretroviral therapy (HAART) regimens, 3 of which contained EFV, pregnancy and birth outcomes were evaluated among female participants enrolled in a randomized clinical trial in Botswana. Before enrollment, all female participants indicated a willingness to avoid pregnancy for the 3-year duration of the study. Monthly urine pregnancy testing and regular contraceptive education and counseling were given to all women on study.

RESULTS

Four hundred fifty-one (69.4%) of 650 enrolled study participants were female and experienced 71 pregnancies, for a rate of 7.9 per 100 person-years during the study. The mean time from HAART initiation to time of first pregnancy was 385 days. The median birth weight of babies was 2950 g (interquartile range: 2700-3250 g); the gender of babies (24 female and 15 male) and occurrence of early pregnancy loss (42%) and stillbirths (3%) did not differ between EFV- and non-EFV-exposed pregnancies (P=0.7). First-trimester EFV exposure occurred in 38 (53.5%) of the 71 pregnancies; 22 (57.9%) of these 38 pregnancies resulted in live births. One infant (4.5%) of the 22 EFV-exposed live births had a congenital abnormality with right limb shortening that was assessed to be unrelated to EFV exposure.

CONCLUSIONS

The restoration of health and longevity in many HAART-treated women is often accompanied by childbearing, as evidenced by the large fraction of women in our cohort who became pregnant despite their initial statements of intent to avoid pregnancy. Of 22 first-trimester EFV-exposed live births, 1 neonate was found to have a major congenital abnormality; however, this defect was unrelated to EFV exposure. The small sample size is insufficient to estimate accurately the underlying risk of congenital malformation after exposure to EFV in early pregnancy, underscoring the importance of reporting to the existing international Antiretroviral Pregnancy Registry. In addition to accessing safe and effective HAART regimens, HIV-infected women require access to comprehensive family planning services, including contraception and procreation counseling.

AIDS in pregnancy, part I: epidemiology, testing, effect on disease progression, opportunistic infections, and risk of vertical transmission

Contribution of acquired immunodeficiency syndrome/human immunodeficiency virus (HIV) infection to pregnancy mortality rates is difficult to estimate; however, it appears to be one of the leading causes of death, at least in developing countries. Prenatal HIV testing affords the best opportunity for the prevention of perinatal HIV transmission. Rapid HIV testing substantially increases the proportion of women who obtain HIV results compared with conventional enzyme-linked immunosorbent assay testing, thus maximizing perinatal HIV interventions. Pregnancy appears to have no effect on the course of HIV disease. Infections due to a variety of pathogens influence the clinical course of the HIV infection and may complicate pregnancy and increase maternal mortality. The main risk factors for mother-to-child HIV transmission are high maternal viral load and CD4 cell count <700 cells/mm3. The main protective factor is antiretroviral therapy.

Reproductive Choice for Women and Men Living with HIV: Contraception, Abortion and Fertility

From a policy and programmatic point of view, this paper reviews the literature on the fertility-related needs of women and men living with HIV and how the entry points represented by family planning, sexually transmitted infection and HIV-related services can ensure access to contraception, abortion and fertility services for women and men living with HIV. Most contraceptive methods are safe and effective for HIV positive women and men. The existing range of contraceptive options should be available to people living with HIV, along with more information about and access to emergency contraception. Potential drug interaction must be considered between hormonal contraception and treatment for tuberculosis and certain antiretroviral drugs. Couples living with HIV who wish to use a permanent contraceptive method should have access to female sterilisation and vasectomy in an informed manner, free of coercion. How to promote condoms and dual protection and how to make them acceptable in long term-relationships remains a challenge. Both surgical and medical abortion are safe for women living with HIV. To reduce risk of vertical transmission of HIV and in cases of infertility, people with HIV should have access to sperm washing and other assisted conception methods, if these are available. Simple and cost-effective procedures to reduce risk of vertical transmission should be part of counselling for women and men living with HIV who intend to have children. Support for the reproductive rights of people with HIV is a priority. More operations research on best practices is needed.

Pregnancy outcomes in HIV-infected and uninfected women in rural and urban South Africa

OBJECTIVE

To describe pregnancy outcomes among clade C HIV-infected and uninfected women in South Africa.

DESIGN

A longitudinal cohort study.

METHODS

Pregnant women attending 9 rural/urban antenatal clinics were prospectively recruited and followed up. Women were seen at the clinic or at home after delivery on 4 occasions after enrollment: 2 times within the first 2 weeks of the newborn's life at home, and every 2 weeks thereafter until their first health clinic visit when the infant was 6 weeks old.

RESULTS

A total of 3465 women were enrolled; 615 withdrew after delivery, moved away, or had a missing or indeterminate HIV status, leaving 2850 women (1449 HIV-infected women). Six women died after delivery and there were 17 spontaneous abortions and 104 stillbirths. An adverse pregnancy outcome was independently associated with HIV infection (adjusted odds ratio [AOR] = 1.63; P = 0.015), urban enrollment (AOR = 0.39; P = 0.020), and nonhospital delivery (AOR = 13.63; P < 0.001) as well as with a CD4 count <200 cells/mL among HIV-infected women (AOR = 1.86; P = 0.127). Among 2529 singleton liveborn babies, birth weight was inversely associated with maternal HIV (AOR = 1.45; P = 0.02) and maternal middle upper arm circumference (AOR = 0.93; P < 0.001). Early infant mortality was not significantly associated with maternal HIV (hazard ratio [HR] = 1.18; P = 0.52) but was with urban sites (HR = 0.34; P = 0.045). Low birth weight substantially increased mortality (AOR = 8.3; P < 0.001). HIV status of infants by 8 weeks of age (14.6%, 95% confidence interval: 12.5% to 17.0%) was inversely associated with maternal CD4 cell count and birth weight.

CONCLUSIONS

HIV-infected women are at a significantly increased risk of adverse pregnancy outcomes. Low-birth-weight infants of HIV-infected and uninfected women are at substantially increased risk of dying.

Desire for a child among women living with HIV/AIDS in northeast Brazil

In Brazil, an increasing proportion of new HIV infections and AIDS cases involve women of reproductive age. To describe the reproductive desire of women with HIV/AIDS and to identify factors associated with the desire for motherhood, a cross-sectional study was carried out in the referral hospital for infectious diseases in Ceará State, northeast Brazil. In total, 229 women were included in data analysis. Median age was 32 years (interquartile range, 26-37), and 63% had a monthly family income of less than 210 USD. Forty-nine percent were using a contraceptive method, and 37% wished to undergo tubal ligation. Sixty-four percent of the latter women were motivated by the fear of having an HIV-positive child. Forty percent of the participants wanted to have a child. In the multivariate regression analysis, variables independently associated with women's desire to have a child were: younger age (in years, odds ration [OR] = 0.94; 95% confidence interval [CI]: 0.90-0.98), number of children (OR = 0.73; 95% CI: 0.57-0.96), and partner's desire for a child (OR = 3.35; 95%CI: 1.75-6.39). Having a partner who did not know about the woman's positive serostatus was negatively associated with the woman's desire for a child (OR = 0.17; 95% CI: 0.04-0.69). No variable related to clinical status was significantly associated with the outcome variable. Our data showed that many unsterilized HIV-positive women in northeast Brazil, at whatever stage of illness, have a desire for children. We recommend that nondirective counseling, consisting of helping women evaluate their own feelings, goals and needs with respect to reproductive options be provided.

The potential impact of antiretroviral therapy on fertility in sub-Saharan Africa

Approximately 14 million women of child-bearing age are living with HIV/AIDS in sub-Saharan Africa. Women with HIV infection have between 25% and 40% lower fertility than noninfected women. As antiretroviral (ARV) therapy becomes increasingly accessible in sub-Saharan Africa, it is important to understand whether and how the associated clinical improvements correspond with changes in the incidence of pregnancy and fertility. Accordingly, this paper reviews the literature on the potential impact of ARV therapy on the fertility of women with HIV infection in sub-Saharan Africa. We use Bongaarts' proximate determinants of fertility framework (adapted for conditions of a generalized HIV epidemic) to examine the underlying mechanisms through which use of ARV therapy may impact the fertility of women with HIV infection. A conceptual framework is proposed to guide future research aimed at understanding how widespread use of ARV therapy may impact fertility in sub-Saharan Africa.

Desire for children and pregnancy risk behavior among HIV-infected men and women in Uganda

To identify ways to improve prevention of mother-to-child transmission (PMTCT) of HIV, we conducted a cross-sectional study of 1,092 HIV-infected men and women attending an AIDS support organization in Jinja, Uganda, between October 2003 and June 2004. Pregnancy risk behavior was defined as having sex without contraceptive or condom. Overall, 42% of participants were sexually active, 33% practiced pregnancy risk behavior, and 18% desired more children. Men were almost four times to want more children than the women (27% vs. 7%). Among those practicing pregnancy risk behavior, 73% did not want more children and were at high risk for unwanted pregnancies. Although 81% knew that mother-to-child transmission of HIV could be prevented, only 22% believed that an HIV-infected woman who received PMTCT therapy could still deliver an HIV-infected child. Lack of MTCT information, having attended the program for </=2 years and desire for children were independently associated with pregnancy risk behavior. PMTCT and other HIV prevention and care programs should ensure provision of family planning for HIV-infected populations who do not want to become pregnant.

Trends in HIV prevalence among pregnant women in Italy, 1994 to 2002

OBJECTIVE

The aim of the study was to analyze the trends in HIV prevalence among childbearing women through unlinked anonymous testing of newborns.

METHODS

Dried-blood specimens, residual to routine metabolic screening of newborns, were collected in Italy during the last quarter of each year, from 1994 to 2002. These samples were tested anonymously for HIV antibodies.

RESULTS

Of 844,311 specimens tested, 703 (0.83/1000; 95% confidence interval, 0.76-0.88) resulted as HIV antibody-reactive. Prevalence was 1.05 per 1000 in 1994 and decreased significantly over the following 3 years, reaching 0.60 per 1000 in 1997. Thereafter, a seroprevalence increase was recorded with a figure of 1.01 per 1000 in 1999. A decrease was again observed in 2001 and in 2002, when the seroprevalence rate was significantly lower than that recorded in 1994. During the entire study period, higher prevalence rates were observed in northern Italian regions, where the highest AIDS incidence rates are recorded, and in metropolitan compared with nonmetropolitan areas. The estimated number of children born each year to an HIV-positive mother ranged from 313 to 546.

CONCLUSION

The number of children born to an HIV-positive mother calls for continued efforts to prevent vertical transmission of the infection.

Increasing likelihood of further live births in HIV-infected women in recent years

OBJECTIVE

To examine how the subsequent childbearing of HIV-infected mothers enrolled in the European Collaborative Study (ECS) has changed over time and identify factors predictive of further childbearing.

DESIGN

Prospective cohort study.

SETTING

Centres in nine European countries included in the ECS, enrolled between end 1986 and November 2003.

POPULATION

HIV-infected women (3911): 3693 with only one and 218 with subsequent live births.

METHODS

Univariable and multivariable logistic regression analyses to obtain odds ratios (OR) and 95% confidence intervals (CI). Kaplan-Meier (KM) analyses to estimate cumulative proportions of women having a subsequent live birth.

MAIN OUTCOME MEASURES

Subsequent live birth.

RESULTS

In multivariable analysis adjusting for time period, ethnicity, maternal age and parity, black women were more likely [adjusted odds ratio (AOR) 2.45; 95% CI, 1.75-3.43], and women >30 years less likely (AOR 0.54, 0.37-0.80), to have a subsequent live birth. Time to subsequent live birth significantly shortened over time, with an estimated 2% of women having a subsequent live birth within 24 months of enrollment pre-1989 versus 14% in 2000-2003 (P < 0.001). Estimated time to subsequent live birth was shorter for black than for white women (P < 0.001).

CONCLUSIONS

The likelihood of subsequent live births substantially increased after 1995 and birth intervals were shorter in women on HAART and among black women. Numbers are currently too small to address the issue of advantages and disadvantages in the management of subsequent deliveries.

Sex and the course of HIV infection in the pre- and highly active antiretroviral therapy eras

We reviewed the available literature on the potential effects of sex on the course of HIV infection and found that there is little evidence for sex differences in the rate of disease progression in the pre-highly active antiretroviral therapy (HAART) and HAART era. Compared to men, women appeared to have lower HIV RNA levels and higher CD4 cell counts shortly after infection with HIV, but studies were inconclusive regarding whether these differences diminish over time. Differences in viral load or CD4+ cell count might cause women to delay initiation of HAART. Nonetheless, we found no substantial sex difference in the benefit of antiretroviral therapy. The studies we reviewed failed to find any harmful effect of pregnancy on HIV disease progression. With the availability of effective antiretroviral agents, HIV-infected women have increasingly decided to have children. Conflicting results exist on the effect of HAART on regression of cervical intra-epithelial neoplasia (CIN). Unlike CIN, invasive cervical cancer has not been found to be much higher in HIV-infected women than in HIV-uninfected women. Although publication bias cannot be ruled out, published studies suggest higher rates of adverse events among HIV-infected women on therapy as compared to men. As more pharmacological agents are developed, it is especially important that potential sex differences in pharmacodynamics are assessed. The relationship between metabolic abnormalities, changes in body habitus, and endocrine perturbations has not been extensively studied. Whether sex differences are due to unalterable genetic factors or social and environmental conditions, it is imperative that all HIV-infected individuals have equal access to interventions that can slow disease progression.

The impact of health care providers on female sterilization among HIV-positive women in Brazil

This paper explores the reproductive preferences and outcomes of HIV-positive women in two cities in Brazil. We used three types of data, all drawn from women who delivered in public sector hospitals: (1) clinical records of 427 HIV-positive women; (2) pre- and postpartum in-depth interviews with 60 HIV-positive women; and (3) a prospective survey carried out among 363 women drawn from the general population. The HIV-positive samples were collected on women who had prenatal care between July 1999 and June 2000, and the general population survey was conducted with women who started prenatal care between April 1998 and June 1999. Among the women in the clinic sample, we found dramatic differences in the proportion sterilized postpartum: 51% in Sao Paulo vs. 4% in Porto Alegre, compared to 3.4% and 1.1%, respectively, of women in the general population. Our qualitative data suggest that HIV-positive women in this study had strong preferences to have no more future children and that female sterilization was the preferred way to achieve this end. Therefore, we conclude that the large difference in rates is mainly due to HIV-positive women's differential access to sterilization in the two settings. In-depth interviews revealed that women in Sao Paulo were often encouraged by clinic staff to be sterilized postpartum. In contrast, HIV-positive women in Porto Alegre clinics were not offered sterilization as an option and those who requested it were repeatedly put off. The striking difference found in the frequency with which doctors provide postpartum sterilization to seropositive women in our study sites deserves attention and discussion in the respective medical communities. At the higher level of national policy on reproductive rights, there may be grounds for reopening discussion about the norms regarding postpartum procedures, and for devoting far more resources to expanding contraceptive options.

Trends in Pregnancy Rates Among Women With Human Immunodeficiency Virus

OBJECTIVE

To describe factors associated with pregnancy and trends in pregnancy rates among women with human immunodeficiency virus (HIV) before and after the release of U.S. Public Health Service Guidelines for the Use of Zidovudine and the Increased Availability of Highly Active Antiretroviral Therapy.

METHODS

Human immunodeficiency virus (HIV)-infected women aged 15 to 44 years who were enrolled in the Adult/Adolescent Spectrum of HIV Disease Project, a medical records cohort study of HIV-infected persons conducted in more than 100 U.S. health care facilities.

RESULTS

Among 8857 women, there were 1185 incident pregnancies during 21617 person-years of follow-up from 1992 through 2001. Pregnancy rate at enrollment was 16%; thereafter, an average of 5.5% of women became pregnant annually. Pregnancies were more likely to occur in women aged 15 to 24 years (adjusted rate ratio [RR] 9.2; 95% confidence interval [CI] 7.4, 11.3) and 25 to 34 years (adjusted RR 4.0; 95% CI 3.3, 4.9) than in women aged 35 to 44 years. Pregnancies were less likely to occur in women with a history of acquired immunodeficiency syndrome (AIDS)-opportunistic illness (adjusted RR 0.4; 95% CI 0.3, 0.5) or a CD4 count below 200 cells/microL and no opportunistic illness (adjusted RR 0.6; 95% CI 0.5, 0.7) than in women with HIV but not AIDS. Higher rates of pregnancy were observed for women prescribed highly active antiretroviral therapy (adjusted RR 1.3; 95% CI 1.0, 1.6) than women prescribed other regimens of antiretroviral therapy. There were significantly higher rates of pregnancy during 1997 through 2001.

CONCLUSION

The increase in pregnancy rates during the era of widespread use of highly active antiretroviral therapy illustrates the continued need for comprehensive prevention and treatment services.

LEVEL OF EVIDENCE

II-2

HIV-1 disease progression and fertility: the incidence of recognized pregnancy and pregnancy outcome in Uganda

OBJECTIVES

To estimate the association between HIV disease progression and the incidence of recognized pregnancy; to estimate the risk of subsequent fetal loss.

METHODS

A total of 191 women (92 HIV seropositive and 99 HIV seronegative at enrolment) aged 15-49 years in an HIV clinical cohort were invited to attend routine clinic visits every 3 months. Information on HIV progression collected at the visit was related to whether there was a pregnancy beginning in the following 3 months. Visits were excluded where the woman was already pregnant, lactating, using modern contraceptives or if there was inadequate follow-up.

RESULTS

There were 2524 eligible visits and 216 recognized pregnancies. The reported frequency of sexual intercourse diminished with advancing HIV disease. The adjusted odds ratio (OR) for pregnancy when the woman was in WHO stage 1 compared with HIV seronegatives was 0.58 [95% confidence interval (CI), 0.36-0.93]; stage 2, 0.47 (95% CI, 0.25-0.91); stage 3, 0.43 (95% CI, 0.25-0.74); and stage 4, (AIDS) 0.14 (95% CI, 0.02-1.09). The findings were similar for CD4 cell count, time from seroconversion and time before AIDS. There was an increase in fetal loss from the early stages of HIV infection (adjusted OR for stage 1, 5.38; 95% CI, 1.57-18.44), there were very few recognized pregnancies in the advanced stages.

CONCLUSIONS

Fertility is reduced from the earliest asymptomatic stage of HIV infection resulting from both a reduced incidence of recognized pregnancy and increased fetal loss. The greatest reduction in fertility was observed following progression to AIDS when there was a very low incidence of recognized pregnancies.

Safe abortion for HIV-positive women with unwanted pregnancy: a reproductive right

About 2.5 million women who become pregnant each year worldwide are HIV-positive. UNAIDS recommends that HIV-positive women should be able to control their fertility and to prevent HIV transmission perinatally if they decide to have children. Yet a literature review on these matters found that termination of pregnancy for HIV-positive women receives very little attention. This paper describes the difficulties faced by HIV-positive women in obtaining safe, legal, affordable abortion services. It shows that voluntary HIV counselling and testing for women seeking induced abortions and post-abortion care may not be provided. HIV-positive women want to avoid pregnancy for the same reasons as other women, but they also do not want to infect their partners through unprotected sex, worry about effects of pregnancy and childbirth on their own health, or about infecting a child and the child's future care. Little research has been done on whether HIV-positive women have a greater risk of morbidity following unsafe abortions than HIV-negative women, but evidence suggests they might. Studies in Zimbabwe and Thailand show that when information and access to legal pregnancy termination are lacking, HIV-positive women may be prevented from terminating a pregnancy. The paper concludes that it is essential for women living with HIV/AIDS to be able to exercise their right to decide whether and when to have children.

The contribution of sexual and reproductive health services to the fight against HIV/AIDS: a review

Approximately 80% of HIV cases are transmitted sexually and a further 10% perinatally or during breastfeeding. Hence, the health sector has looked to sexual and reproductive health programmes for leadership and guidance in providing information and counselling to prevent these forms of transmission, and more recently to undertake some aspects of treatment. This paper reviews and assesses the contributions made to date by sexual and reproductive health services to HIV/AIDS prevention and treatment, mainly by services for family planning, sexually transmitted infections and antenatal and delivery care. It also describes other sexual and reproductive health problems experienced by HIV-positive women, such as the need for abortion services, infertility services and cervical cancer screening and treatment. This paper shows that sexual and reproductive health programmes can make an important contribution to HIV prevention and treatment, and that STI control is important both for sexual and reproductive health and HIV/AIDS control. It concludes that more integrated programmes of sexual and reproductive health care and STI/HIV/AIDS control should be developed which jointly offer certain services, expand outreach to new population groups, and create well-functioning referral links to optimize the outreach and impact of what are to date essentially vertical programmes.