Impact of ART on the fertility of HIV-positive women in sub-Saharan Africa

Triangulation of Routine Antenatal HIV Prevalence Data and Adjusted HIV Estimates in Mozambique

BACKGROUND

Routine health system data are central to monitoring HIV trends. In Mozambique, the reported number of women receiving antenatal care (ANC) and antiretroviral therapy for prevention of mother-to-child transmission (PMTCT) has exceeded the Spectrum-estimated number of pregnant women since 2017. In some provinces, reported HIV prevalence in pregnant women has declined faster than epidemiologically plausible. We hypothesized that these issues are linked and caused by programmatic overenumeration of HIV-negative pregnant women at ANC.

METHODS

We triangulated program-reported ANC client numbers with survey-based fertility estimates and facility birth data adjusted for the proportion of facility births. We used survey-reported ANC attendance to produce adjusted time series of HIV prevalence in pregnant women, adjusted for hypothesized program double counting. We calibrated the Spectrum HIV estimation models to adjusted HIV prevalence data to produce adjusted adult and pediatric HIV estimates.

RESULTS

ANC client numbers were not consistent with facility birth data or modeled population estimates indicating ANC data quality issues in all provinces. Adjusted provincial ANC HIV prevalence in 2021 was median 45% [interquartile range 35%-52% or 2.3 percentage points (interquartile range 2.5-3.5)] higher than reported HIV prevalence. In 2021, calibrating to adjusted antenatal HIV prevalence lowered PMTCT coverage to less than 100% in most provinces and increased the modeled number of new child infections by 35%. The adjusted results better reconciled adult and pediatric antiretroviral treatment coverage and antenatal HIV prevalence with regional fertility estimates.

CONCLUSIONS

Adjusting HIV prevalence in pregnant women using nationally representative household survey data on ANC attendance produced estimates more consistent with surveillance data. The number of children living with HIV in Mozambique has been substantially underestimated because of biased routine ANC prevalence. Renewed focus on HIV surveillance among pregnant women would improve PMTCT coverage and pediatric HIV estimates.

Comparison of programmatic data from antenatal clinics with population-based HIV prevalence estimates in the era of universal test and treat in western Kenya

OBJECTIVE

To compare HIV prevalence estimates from routine programme data in antenatal care (ANC) clinics in western Kenya with HIV prevalence estimates in a general population sample in the era of universal test and treat (UTT).

METHODS

The study was conducted in the area covered by the Siaya Health Demographic Surveillance System (Siaya HDSS) in western Kenya and used data from ANC clinics and the general population. ANC data (n = 1,724) were collected in 2018 from 13 clinics located within the HDSS. The general population was a random sample of women of reproductive age (15-49) who reside in the Siaya HDSS and participated in an HIV sero-prevalence survey in 2018 (n = 2,019). Total and age-specific HIV prevalence estimates were produced from both datasets and demographic decomposition methods were used to quantify the contribution of the differences in age distributions and age-specific HIV prevalence to the total HIV prevalence estimates.

RESULTS

Total HIV prevalence was 18.0% (95% CI 16.3-19.9%) in the ANC population compared with 18.4% (95% CI 16.8-20.2%) in the general population sample. At most ages, HIV prevalence was higher in the ANC population than in the general population. The age distribution of the ANC population was younger than that of the general population, and because HIV prevalence increases with age, this reduced the total HIV prevalence among ANC attendees relative to prevalence standardised to the general population age distribution.

CONCLUSION

In the era of UTT, total HIV prevalence among ANC attendees and the general population were comparable, but age-specific HIV prevalence was higher in the ANC population in most age groups. The expansion of treatment may have led to changes in both the fertility of women living with HIV and their use of ANC services, and our results lend support to the assertion that the relationship between ANC and general population HIV prevalence estimates are highly dynamic.

Fertility trends by HIV status in a health and demographic surveillance study in Magu District, Tanzania, 1994-2018

BACKGROUND

Sub-Saharan Africa (SSA) has the highest fertility rates and highest HIV disease burden globally. However, it is not clear how the rapid expansion of anti-retroviral therapy (ART) for HIV has impacted the fertility gap between HIV-infected and uninfected women. We used data from a Health and Demographic Surveillance System (HDSS) in north-western Tanzania to explore trends in fertility rates and the relationship between HIV and fertility over the 25-year period.

METHODS

From 1994 to 2018, births and population denominators from the HDSS population were used to obtain age-specific fertility rates (ASFRs) and total fertility rates (TFRs). HIV status was extracted from eight rounds of epidemiologic serological surveillances (1994-2017). Fertility rates by HIV status and in different levels of ART availability were compared over time. Independent risk factors for fertility changes were examined using Cox proportional hazard models.

RESULTS

There were 24,662 births from 36,814 women (15-49) who contributed a total of 145,452.5 Person-Years of follow-ups. The TFR declined from 6.5 births per woman in 1994-1998 to 4.3 births per woman in 2014-2018. The number of births per woman was 40% lower in women living with HIV than in HIV-uninfected women (4.4 vs. 6.7), although this difference narrowed over time. The fertility rate in HIV-uninfected women was 36% lower in 2013-2018 than in 1994-1998(age-adjusted HR = 0.641; 95% CI 0.613-0.673). In contrast, the fertility rate in women living with HIV was relatively unchanged over the same follow up period (age-adjusted HR = 1.099; 95% CI 0.870-1.387).

CONCLUSIONS

There was a notable fertility decline among women in the study area from 1994 to 2018. Fertility remained lower in women living with HIV than in HIV-uninfected women, but the difference continued to narrow over time. These results highlight the need for more research into fertility changes, fertility desire and family planning use in Tanzanian rural communities.

Predictors of adverse pregnancy outcomes among Kenyan women with HIV on antiretroviral treatment in pregnancy

OBJECTIVE

The aim of this study was to understand predictors of adverse pregnancy outcomes (APOs) among women on antiretroviral treatment (ART).

DESIGN

A longitudinal cohort.

METHODS

Participants from the Mobile WAChX trial were evaluated for APOs, including stillbirth (fetal death at ≥20 weeks' gestation), preterm birth (PTB, livebirth at <37 weeks' gestation,) and neonatal death (NND, ≤28 days after live birth). Predictors were determined by univariable and multivariable Cox proportional hazards and log-binomial models.

RESULTS

Among 774 women included, median age was 27 years and 29.0% had unsuppressed HIV viral load (>1000 copies/ml) at enrollment. Half (55.1%) started ART prepregnancy, 89.1% on tenofovir-based regimens. Women with depression had a higher risk of stillbirth (adjusted hazard ratio [aHR] 2.93, 95% confidence interval (95% CI) 1.04-8.23), and women with lower social support score had higher risk of late stillbirth (aHR 11.74, 2.47-55.86). Among 740 livebirths, 201 (27.2%) were preterm and 22 (3.0%) experienced NND. PTB was associated with unsuppressed maternal viral load (adjusted prevalence ratio [aPR] 1.28, 95% CI 1.02-1.61), intimate partner violence (IPV) in pregnancy (aPR 1.94, 95% CI 1.28-2.94), and history of any sexually transmitted infection (STI) (aPR 1.63, 95% CI 1.06-2.51). NND was associated with PTB (aPR 2.53, 95% CI 1.10-5.78) and STI history (aPR 4.25, 95% CI 1.39-13.06). Most associations retained significance in the subgroup of women with viral suppression.

CONCLUSION

Maternal viremia during pregnancy predicted PTB as did IPV, lower education, and STI history, while psychosocial stressors predicted stillbirth. Implementing mental health services, ART adherence, partner support, and routine STI screening and treatment could reduce APOs among women with HIV in sub-Saharan Africa settings.

Prevalence and factors associated with fertility desire among HIV-positive women in Rwanda in the context of improved life expectancy

Background

The knowledge of the key factors associated with fertility desire among people living with HIV/AIDS is crucial for the efficient planning of maternal and child health care programs. Fertility desire has generally increased among women of reproductive age in Rwanda. However, its level and determinants among women living with HIV/AIDS (WLHA) are currently not well known in the context of Rwanda. The present study aimed to fill in this knowledge gap.

Methods

Data were extracted from the 2015 Rwanda demographic and health survey (RDHS) for 243 HIV-positive women of reproductive age. Univariate and multivariable logistic regression analyses were conducted in order to identify the most influential factors.

Results

The prevalence of desire to have another child in HIV-positive women was found to be as high as 40.7%. Multivariable logistic regression analyses showed that the woman’s age of 35–49 years (AOR = 0.051, 95% CI: 0.013–0.204), woman’s parity of 3 children or above (AOR = 0.177, 95% CI: 0.037–0.837), being employed (AOR = 0.298, 95% CI: 0.113–0.782) and currently using contraceptives (AOR = 0.146; 95% CI: 0.057–0.375) were significantly associated with low odds of fertility desire among HIV- positive women in Rwanda. Women younger than 25 years, with no living child, or who were unemployed or who were not using any contraceptive were significantly associated with greater odds of desire to have another child than did other HIV- positive women. A woman whose partner's desire for children is different  from hers was associated with about four times higher odds (AOR = 3.752; 95% CI: 1.203–11.702) of desire for more children than women who desire the same as their partners.

Conclusion

Fertility desire in WLHA is currently high in Rwanda. It is significantly influenced by demographic and socioeconomic factors. The Rwanda’s health care system should be prepared to intensify the required services for the prevention of the vertical transmission of HIV, the delivery of maternal and child health care services, and the support to WLHA in planning their fertility. Interventions should target low-parity young women, with a particular focus on meeting their contraceptive needs.

Demography of remarriage and fertility desire among women receiving antiretroviral therapy in South West Nigeria

Background: In view of sociocultural norms surrounding marriage and childbearing in South West Nigeria, fertility desire may be stronger among remarried women living with HIV. This article describes the characteristics of remarriage and its relationship to fertility desire.Method: A cross-sectional study was conducted among HIV-positive women aged 18-49 years at the Antiretroviral Treatment (ART) clinic, College of Medicine/University College Hospital, Ibadan, Nigeria between November and December 2015. Data were analysed using descriptive statistics and generalised linear models.Results: Overall, 123 (17.3%) of 711 women had experienced remarriage. Significant factors among remarried women were a lack of formal education (OR_adj = 3.35, CI: 1.46-7.72); polygamous family (OR_adj = 2.65, CI: 1.71-4.12), and serodiscordant union (OR_adj = 1.97, CI: 1.14-3.41). Fertility desire was expressed by 410 women (57.7%). After controlling for demographic, socio-economic, and HIV-care characteristics, remarried women were 2.5 times as likely to have fertility desire compared to their counterparts who never remarried (OR_adj = 2.49, CI: 1.43-4.33). Younger age was significantly associated with higher odds of fertility desire. Other factors negatively associated with fertility desire were education (OR_adj = 0.30, CI: 0.12-0.74) and number of surviving children (OR_adj = 0.28, CI: 0.22-0.34).Conclusion: HIV-care and treatment programmes need to pay attention to reproductive concerns, especially among women in second and higher order marriages.

Effect of HIV Infection and Antiretroviral Treatment on Pregnancy Rates in the Western Cape Province of South Africa

BACKGROUND

Previous studies suggest that untreated human immunodeficiency virus (HIV) infection is associated with a reduced incidence of pregnancy, but studies of the effect of antiretroviral treatment (ART) on pregnancy incidence have been inconsistent.

METHODS

Routine data from health services in the Western Cape province of South Africa were linked to identify pregnancies during 2007-2017 and maternal HIV records. The time from the first (index) pregnancy outcome date to the next pregnancy was modeled using Cox proportional hazards models.

RESULTS

During 2007-2017, 1 042 647 pregnancies were recorded. In all age groups, pregnancy incidence rates were highest in women who had started ART, lower in HIV-negative women, and lowest in ART-naive HIV-positive women. In multivariable analysis, after controlling for the most recent CD4+ T-cell count, pregnancy incidence rates in HIV-positive women receiving ART were higher than those in untreated HIV-positive women (adjusted hazard ratio, 1.63; 95% confidence interval, 1.59-1.67) and those in HIV-negative women.

CONCLUSION

Among women who have recently been pregnant, receipt of ART is associated with high rates of second pregnancy. Better integration of family planning into HIV care services is needed.

Fertility desire and associated factors among people living with HIV in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Increased Anti-Retroviral Therapy (ART) coverage improves health status and the survival of people living with Human Immunodeficiency Virus (HIV) as a result, reproductive health needs of the clients are increased. As part of continuum HIV care, understanding fertility desire and reproductive health care needs of HIV positive peoples will play paramount role in planning and delivering appropriate health services. The finding of studies conducted on the fertility desire and associated factors among People Living with HIV in Ethiopia presented inconclusive. Therefore, this study aimed to assess the pooled prevalence of fertility desire and associated factors among people living with HIV in Ethiopia.

METHODS

A total of 26 studies conducted in Ethiopia were included in this Meta-analysis. Pub Med, HINARI, Google scholar and Google data bases were searched. Data from the included articles were extracted using a standardized data extraction tool. The included studies were analyzed using a random effects meta-analysis model. Analysis was done Using STATA version 14 statistical software. Heterogeneity was assessed statistically using the standard Chi-square, I^2. The association between fertility desire and factors were examined using a random effects model.

RESULT

In this meta-analysis, the pooled prevalence of fertility desire in Ethiopia is 42.21% (95%CI 39.18, 45.25). Fertility desire is significantly associated with sex: being female (OR = 0.71,95%CI 0.57,0.86), partners desire (OR = 16.8, 95% CI: 9.45, 29.88), not having child (OR = 5.46 95%CI 4.24, 7.040), age < 30(OR = 2.34, 95%CI 2.10, 2.60), formal education (OR = 1.31 95%CI 1.09, 1.59)). However, use of family planning, residence, and Knowledge on Prevention of Mother to Child Transmission and disclosure status didn't show association with fertility desire.

CONCLUSION

In this finding, significant people of living with HIV have a desire to have a child. The finding showed the need to strengthen fertility desire and reproductive health care needs of HIV positive peoples. Therefore, strengthening the integration of fertility related issues with HIV continuum care will play a paramount role in averting risky sexual behaviors and Prevention of Mother to Child Transmission among peoples on ART.

Challenges in estimating HIV prevalence trends and geographical variation in HIV prevalence using antenatal data: Insights from mathematical modelling

BACKGROUND

HIV prevalence data among pregnant women have been critical to estimating HIV trends and geographical patterns of HIV in many African countries. Although antenatal HIV prevalence data are known to be biased representations of HIV prevalence in the general population, mathematical models have made various adjustments to control for known sources of bias, including the effect of HIV on fertility, the age profile of pregnant women and sexual experience.

METHODS AND FINDINGS

We assessed whether assumptions about antenatal bias affect conclusions about trends and geographical variation in HIV prevalence, using simulated datasets generated by an agent-based model of HIV and fertility in South Africa. Results suggest that even when controlling for age and other previously-considered sources of bias, antenatal bias in South Africa has not been constant over time, and trends in bias differ substantially by age. Differences in the average duration of infection explain much of this variation. We propose an HIV duration-adjusted measure of antenatal bias that is more stable, which yields higher estimates of HIV incidence in recent years and at older ages. Simpler measures of antenatal bias, which are not age-adjusted, yield estimates of HIV prevalence and incidence that are too high in the early stages of the HIV epidemic, and that are less precise. Antenatal bias in South Africa is substantially greater in urban areas than in rural areas.

CONCLUSIONS

Age-standardized approaches to defining antenatal bias are likely to improve precision in model-based estimates, and further recency adjustments increase estimates of HIV incidence in recent years and at older ages. Incompletely adjusting for changing antenatal bias may explain why previous model estimates overstated the early HIV burden in South Africa. New assays to estimate the fraction of HIV-positive pregnant women who are recently infected could play an important role in better estimating antenatal bias.

Fertility among women living with HIV in western Ethiopia and : a cross-sectional study

OBJECTIVE

This study aimed to examine fertility (live births) in the last 3 years and its associated factors among women living with HIV (WLHIV) in western Ethiopia .

DESIGN

Participants were recruited into a cross-sectional survey using systematic sampling.

SETTINGS

Four healthcare facilities in western Ethiopia were included.

PARTICIPANTS

Eligible participants were WLHIV of reproductive age (15-49 years) from western Ethiopia who found out about their HIV-positive status more than 3 years ago (N=866).

PRIMARY OUTCOME MEASURES

The fertility (live births) of HIV-positive women in the last 3 years was surveyed using face-to-face interviews (March-June 2018). Logistic regression analyses were conducted to examine factors influencing fertility in the last 3 years.

RESULTS

A total of 108 (12.5%) HIV-positive women gave birth to 121 live children in the last 3 years. Of these births, 18.2% were reported as mistimed at conception, while 26.4% were reported as unwanted. Of the live births, 8.3% ended in death. Of the 76 (62.8%) children with known HIV status born to HIV-positive women in the last 3 years, 7.9% were HIV-positive. In terms of predictors of fertility, women aged 15-24 years (adjusted OR (AOR) 2.72; 95% CI 1.14 to 6.49) and 25-34 years (AOR 4.34; 95% CI 2.61 to 7.21) had increased odds of fertility compared with women aged 35-49 years. Women using antiretroviral therapy (ART) for less than 5 years were more likely to have given birth in the last 3 years compared with those using ART for 10 years or more (AOR 2.96; 95% CI 1.19 to 7.36), even after controlling for age.

CONCLUSIONS

WLHIV in Ethiopia are having children and so it is imperative that safe conception strategies are readily available as well as support to reduce HIV-related risks for children born to these mothers. Strengthening reproductive health services for HIV-positive women in order to achieve their family planning goals is therefore important.

Changing Childbearing Norms During an Era of ART Expansion in Malawi, 2009 to 2015

Community norms shape the childbearing goals and behaviors of persons living with HIV/AIDS (PLWHA) but little is known about how norms around HIV-positive childbearing have changed with expanded access to antiretroviral treatment (ART). We analyze data collected in 2009 and 2015 by the Tsogolo la Thanzi (TLT) project-a longitudinal, population-based study of young adults in southern Malawi. Respondents were asked about the acceptability of childbearing using vignettes that varied a hypothetical couple's HIV status and number of children. We assess mean differences in support for childbearing over time and by respondent gender and serostatus. The acceptability of childbearing for PLWHA increased dramatically over the 6-year period; however, support levels varied based on a couple's current number of children and whether they were seropositive concordant or discordant. Differences in attitudes by gender and HIV status diminished over time, pointing to a population-level convergence in norms about acceptable childbearing.

Planning a family in Nairobi's informal settlements: results of a qualitative study

Childbearing intentions among women in high-fertility contexts are usually classified into those wanting to have a baby, those wanting to 'space' a birth and those wanting to 'limit' their family size. However, evidence from Africa increasingly suggests that women's intentions are more complex than this classification suggests, and that there is fluidity in these intentions. This research explores women's accounts of their childbearing intentions and decisions in order to examine how this fluidity plays out in a low-fertility context in urban Africa. Six focus group discussions were conducted in April and May 2012 with women of reproductive age in Nairobi, Kenya. Participants were recruited using random and purposive sampling techniques. The focus group discussions had an average of seven participants each. Data were coded thematically and analysed using Nvivo software. The analysis explored the factors that women consider to be influential for childbearing and found that the health of the mother and child, costs of raising a child and relationships were commonly reported to be important. Evidence of intentions to space births and limit family size was found. However, the data also showed that there is fluidity in women's family planning intentions, driven by changes in relationships or household finances, which often result in a desire to avoid pregnancy in the present moment. The fluidity observed in women's childbearing intentions cannot be accounted for by the concepts of either 'spacing' or 'limitation' but is best explained by the concept of 'postponement'. The research reveals the need for family planning clinics to provide a full method mix, as well as high-quality counselling, to enable women to choose a method that best suits their needs.

Subfertility among HIV-affected couples in a safer conception cohort in South Africa

BACKGROUND

Subfertility among couples affected by HIV has an impact on the well-being of couples who desire to have children and may prolong HIV exposure. Subfertility in the antiretroviral therapy era and its determinants have not yet been well characterized.

OBJECTIVE

The objective of the study was to investigate the burden and determinants of subfertility among HIV-affected couples seeking safer conception services in South Africa.

STUDY DESIGN

Nonpregnant women and male partners in HIV seroconcordant or HIV discordant relationships desiring a child were enrolled in the Sakh'umndeni safer conception cohort at Witkoppen Clinic in Johannesburg between July 2013 and April 2017. Clients were followed up prospectively through pregnancy (if they conceived) or until 6 months of attempted conception, after which they were referred for infertility services. Subfertility was defined as not having conceived within 6 months of attempted conception. Robust Poisson regression was used to assess the association between baseline characteristics and subfertility outcomes; inverse probability weighting was used to account for missing data from women lost to safer conception care before 6 months of attempted conception.

RESULTS

Among 334 couples enrolled, 65% experienced subfertility (inverse probability weighting weighted, 95% confidence interval, 0.59-0.73), of which 33% were primary subfertility and 67% secondary subfertility. Compared with HIV-negative women, HIV-positive women not on antiretroviral therapy had a 2-fold increased risk of subfertility (weighted and adjusted risk ratio, 2.00; 95% confidence interval, 1.19-3.34). Infertility risk was attenuated in women on antiretroviral therapy but remained elevated, even after ≥2 years on antiretroviral therapy (weighted and adjusted risk ratio, 1.63; 95% confidence interval, 0.98-2.69). Other factors associated with subfertility were female age (weighted and adjusted risk ratio, 1.03, 95% confidence interval, 1.01-1.05 per year), male HIV-positive status (weighted and adjusted risk ratio, 1.31; 95% confidence interval, 1.02-1.68), male smoking (weighted and adjusted risk ratio, 1.29; 95% confidence interval, 1.05-1.60), and trying to conceive for ≥1 year (weighted and adjusted risk ratio, 1.38; 95% confidence interval, 1.13-1.68).

CONCLUSION

Two in 3 HIV-affected couples experienced subfertility. HIV-positive women were at increased risk of subfertility, even when on antiretroviral therapy. Both male and female HIV status were associated with subfertility. Subfertility is an underrecognized reproductive health problem in resource-limited settings and may contribute to prolonged HIV exposure and transmission within couples. Low-cost approaches for screening and treating subfertility in this population are needed.

Unintended Pregnancy in Women Living with HIV in Sub-Saharan Africa: A Systematic Review and Meta-analysis

In 2014, about 1.5 million pregnancies occurred among HIV-positive women in low and middle-income countries. To pool magnitude and factors associated with unintended pregnancy in women living with HIV in sub-Saharan Africa, a systematic search of electronic databases was undertaken in November 2016. Pooling the magnitude of unintended pregnancy reported by 14 studies yielded a crude summary prevalence of 55.9%. The magnitude of unwanted pregnancy and mistimed pregnancy in six studies ranged from 14 to 59 and 9 to 47.2%, respectively. Contraceptive failure was an important factor for many unintended pregnancies. The magnitude of unintended pregnancy was significantly higher in HIV-positive women than for HIV-negative women in three out of six studies. The available evidence suggests that there is a high magnitude of unintended pregnancy in this population. Improving effective contraceptive utilization is thus a priority to address unintended pregnancies and to prevent mother to child transmission of HIV. PROSPERO Number: CRD42016051310.

Reduced fecundity in HIV-positive women

STUDY QUESTION

Is HIV associated with increased time to pregnancy (TTP)?

SUMMARY ANSWER

HIV-positive women who discontinue a contraceptive method to become pregnant have increased TTP, particularly among those who likely do not know their status.

WHAT IS KNOWN ALREADY

HIV-positive women have fewer children on average than their HIV-negative counterparts due to both behavioral and biological factors. There is a need to better describe and quantify fecundity patterns associated with HIV in the general population.

STUDY DESIGN, SIZE, DURATION

This cross-sectional study was based on data from 12 Demographic and Health Surveys (DHSs) conducted between 2003 and 2013 in 11 African countries. All studies collected dried blood spot samples for HIV testing and included a retrospective calendar module that recorded women's monthly reproductive status in the 5 years preceding the survey. TTP was measured among 3181 women discontinuing a contraceptive method within 2 years of the survey in order to become pregnant.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We use Cox proportional hazard models for discrete survival data to model TTP and estimate fecundability odds ratios (FOR) and 95% CIs for the 12-month period following contraceptive discontinuation. In addition to employing a binary measure of HIV status, we also develop an additional explanatory measure that combines HIV status with information on whether respondents had ever been tested for HIV and received their results (which proxies for knowledge of HIV status) to reduce the threat of confounding from behavioral changes following an HIV diagnosis.

MAIN RESULTS AND THE ROLE OF CHANCE

In our sample, 10.3% of women were HIV-positive, and a little more than half (51.8%) of women received test results and likely knew their status. Over a 12-month observation period, HIV-positive women had a 25% average reduction in fecundity compared to HIV-negative women [adjusted FOR (aFOR) = 0.75 (0.62-0.92)] after adjusting for confounders. The 12-month fecundity patterns differed by women's likely knowledge of their status such that results were primarily driven by HIV-positive women who likely did not know their status. Moreover, reductions in fecundity attributable to HIV were not uniform over time. Among women who were still trying for pregnancy after 3 unsuccessful months, HIV-positive women had half the odds of becoming pregnant compared to HIV-negative women [aFOR = 0.50 (0.35-0.71)]. Conversely, there were no significant differences in FORs between HIV-negative and HIV-positive women in the first 3 months.

LIMITATIONS REASONS FOR CAUTION

Because dried blood spot samples for HIV testing were collected at the time of the survey but reproductive calendar data were collected retrospectively, it is possible that we introduced misclassification bias, as we have no knowledge if the acquisition of HIV occurred before or after pregnancy attempt.

WIDER IMPLICATIONS OF THE FINDINGS

As life expectancy and quality health status improve due to earlier initiation of antiretroviral (ARV) treatment in HIV-positive women, there has been growing awareness that services should also address the fertility desires of HIV-positive women who want children. These findings indicate that if a pregnancy does not occur after 3 months of attempting pregnancy, HIV-positive women and HIV-discordant couples should request access to HIV and reproductive pre-pregnancy counseling and health assessments.

STUDY FUNDING/COMPETING INTEREST(S)

A.G. was supported by the National Institutes of Health (contract T32-HD007275) during the study. During the conceptualization, data collection and analysis time frame, S.vdP. was supported by WHO/RHR/HRP Special Program in Reproductive Health and Research, Geneva, Switzerland, and HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction). The authors have no conflicts of interest to declare.

The multi-country PROMOTE HIV antiretroviral treatment observational cohort in Sub-Saharan Africa: Objectives, design, and baseline findings

BACKGROUND

The PROMOTE study aims to measure long-term antiretroviral treatment (ART) safety and adherence; compare HIV disease progression; assess subsequent adverse pregnancy outcomes; evaluate effect of ART exposure on growth and development in HIV-exposed uninfected children; and assess long-term survival of mothers and children. This report primarily describes cohort characteristics at baseline to better understand long-term outcomes.

METHODS AND FINDINGS

This is a prospective study. HIV-infected mothers and their children originally recruited in a multisite randomized clinical trial for prevention of perinatal HIV transmission were re-enrolled in PROMOTE. A total of 1987 mothers and 1784 children were enrolled from eight sites in Uganda, Malawi, Zimbabwe and South Africa. Most women (≥75%) reported being married in Malawi and Zimbabwe compared to low proportions in South Africa (4.4% in Durban and 15% in Soweto), and 43.5% in Uganda (p<0.001). There were variabilities in contraceptive practices: injectable contraceptive was the commonest reported method (40.9% overall); implant was the second commonest (15.7% overall); oral contraceptives were common in Zimbabwe; and tubal ligation was common in Malawi and South Africa. At baseline, 97.8% of women reported currently using ART; 96.4% were in WHO clinical class 1 or 2; median CD4 cell count was 825 cells per uL; and viral load was undetectable in 1637 (~85%) of the women. Approximately, 14% of women did not inform their primary partners of their own HIV status, 18% reported that they knew their partners were not HIV tested, and 9% did not know if partner was tested. Overall mean age of children at enrollment was 3.5 years; and 5.7% and 25.0% had weight-for-age and height-for-age z-scores <2 standard deviations, respectively.

CONCLUSIONS

These baseline data show high adherence to ART use. However, issues of HIV disclosure and reproductive intentions remain important. In addition to ART and ensuring high adherence, other preventive measures should be included.

Relative patterns of sexual activity and fertility among HIV positive and negative women-Evidence from 46 DHS

Objectives

Projections of fertility of HIV positive women as ART scales up are needed to plan prevention of mother-to-child transmission (PMTCT) services. We describe differences in exposure to pregnancy between HIV positive and HIV negative women by age, region and national ART coverage to evaluate the extent to which behavioural differences explain lower fertility among HIV positive women and assess whether exposure to pregnancy has changed with antiretroviral treatment (ART) scale-up.

Methods

We analysed 46 nationally representative household surveys in sub-Saharan Africa conducted between 2003 and 2015 to estimate risk of exposure to recent sex and pregnancy of HIV positive and HIV negative women by age using a log binomial model. We tested for regional and urban/rural differences and associations with national ART coverage. We estimated an adjusted fertility rate ratio of HIV positive to HIV negative women adjusting for differences in exposure to pregnancy.

Results

Exposure to pregnancy differs significantly between HIV positive and negative women by age, modified by region. Younger HIV positive women have a higher exposure to pregnancy than HIV negative women and the opposite is true at older ages. The switch occurs at 25–29 for rural women and 30–34 for urban women. There was no evidence that exposure to pregnancy of HIV positive women have changed as national ART coverage increased. The inferred rate of fecundity of HIV positive women when adjusted for differences in exposure to pregnancy were lower than unadjusted fertility rate ratios in women aged 20–29 and 20–24 in urban and rural areas respectively varying between 0.6 and 0.9 over regions.

Discussion

The direct effects of HIV on fertility are broadly similar across ages, while the dramatic age gradient that has frequently been observed is largely attributable to variation in relative sexual exposure by age.

The relationship between HIV and fertility in the era of antiretroviral therapy in sub-Saharan Africa: evidence from 49 Demographic and Health Surveys

Objectives

To describe regional differences in the relative fertility of HIV‐positive vs. HIV‐negative women and changes as antiretroviral treatment (ART) is scaled up, to improve estimates of predicted need for and coverage of prevention of mother‐to‐child transmission services at national and subnational levels.

Methods

We analysed 49 nationally representative household surveys in sub‐Saharan Africa between 2003 and 2016 to estimate fertility rate ratios of HIV‐positive and HIV‐negative women by age using exponential regression and test for regional and urban/rural differences. We estimated the association between national ART coverage and the relationship between HIV and fertility.

Results

Significant regional differences exist in HIV and fertility relationships, with less HIV‐associated subfertility in Southern Africa. Age patterns of relative fertility are similar. HIV impact on fertility is weaker in urban than rural areas. For women below age 30, regional and urban/rural differences are largely explained by differences in age at sexual debut. Higher levels of national ART coverage were associated with slight attenuation of the relationship between HIV and fertility.

Conclusions

Regional differences in HIV‐associated subfertility and urban–rural differences in age patterns of relative fertility should be accounted for when predicting need for and coverage of PMTCT services at national and subnational level. Although HIV impacts on fertility are somewhat reduced at higher levels of national ART coverage, differences in fertility between HIV positive and negative remain, and fertility of women on ART should not be assumed to be the same as HIV‐negative women. There were few data in recent years, when ART has reached high levels, and this relationship should continue to be assessed as further evidence becomes available.

Modelling period fertility: Schooling and intervals following a birth in Eastern Africa

We describe a regression-based approach to the modelling of age-, order-, and duration-specific period fertility, using retrospective survey data. The approach produces results that are free of selection biases and can be used to study differential fertility. It is applied to Demographic and Health Survey data for Ethiopia, Kenya, Tanzania, and Zimbabwe to investigate differential trends in fertility by education. Parity progression fell and the intervals following each birth lengthened between the 1970s and 2000s in all four countries. Fertility fell most among women with secondary education. In contrast to other world regions, postponement of successive births for extended periods accounted for much of the initial drop in fertility in these African countries. However, family size limitation by women with secondary education in Ethiopia and Kenya and longer birth spacing in Zimbabwe also played significant roles. Thus, birth control is being adopted in Eastern Africa in response to diverse changes in fertility preferences.

Changes in Fertility at the Population Level in the Era of ART in Rural Malawi

Introduction:

HIV reduces fertility through biological and social pathways, and antiretroviral treatment (ART) can ameliorate these effects. In northern Malawi, ART has been available since 2007 and lifelong ART is offered to all pregnant or breastfeeding HIV-positive women.

Methods:

Using data from the Karonga Health and Demographic Surveillance Site in Malawi from 2005 to 2014, we used total and age-specific fertility rates and Cox regression to assess associations between HIV and ART use and fertility. We also assessed temporal trends in in utero and breastfeeding HIV and ART exposure among live births.

Results:

From 2005 to 2014, there were 13,583 live births during approximately 78,000 person years of follow-up of women aged 15–49 years. The total fertility rate in HIV-negative women decreased from 6.1 [95% confidence interval (CI): 5.5 to 6.8] in 2005–2006 to 5.1 (4.8–5.5) in 2011–2014. In HIV-positive women, the total fertility rate was more stable, although lower, at 4.4 (3.2–6.1) in 2011–2014. In 2011–2014, compared with HIV-negative women, the adjusted (age, marital status, and education) hazard ratio was 0.7 (95% CI: 0.6 to 0.9) and 0.8 (95% CI: 0.6 to 1.0) for women on ART for at least 9 months and not (yet) on ART, respectively. The crude fertility rate increased with duration on ART up to 3 years before declining. The proportion of HIV-exposed infants decreased, but the proportion of ART-exposed infants increased from 2.4% in 2007–2010 to 3.5% in 2011–2014.

Conclusions:

Fertility rates in HIV-positive women are stable in the context of generally decreasing fertility. Despite a decrease in HIV-exposed infants, there has been an increase in ART-exposed infants.

The effects of HIV on fertility by infection duration: evidence from African population cohorts before antiretroviral treatment availability

OBJECTIVES

To estimate the relationship between HIV natural history and fertility by duration of infection in east and southern Africa before the availability of antiretroviral therapy and assess potential biases in estimates of age-specific subfertility when using retrospective birth histories in cross-sectional studies.

DESIGN

Pooled analysis of prospective population-based HIV cohort studies in Masaka (Uganda), Kisesa (Tanzania) and Manicaland (Zimbabwe).

METHODS

Women aged 15-49 years who had ever tested for HIV were included. Analyses were censored at antiretroviral treatment roll-out. Fertility rate ratios were calculated to see the relationship of duration of HIV infection on fertility, adjusting for background characteristics. Survivorship and misclassification biases on age-specific subfertility estimates from cross-sectional surveys were estimated by reclassifying person-time from the cohort data to simulate cross-sectional surveys and comparing fertility rate ratios with true cohort results.

RESULTS

HIV-negative and HIV-positive women contributed 15 440 births and 86 320 person-years; and 1236 births and 11 240 000 person-years, respectively, to the final dataset. Adjusting for age, study site and calendar year, each additional year since HIV seroconversion was associated with a 0.02 (95% confidence interval 0.01-0.03) relative decrease in fertility for HIV-positive women. Survivorship and misclassification biases in simulated retrospective birth histories resulted in modest underestimates of subfertility by 2-5% for age groups 20-39 years.

CONCLUSION

Longer duration of infection is associated with greater relative fertility reduction for HIV-positive women. This should be considered when creating estimates for HIV prevalence among pregnant women and prevention of mother-to-child transmission need over the course of the HIV epidemic and antiretroviral treatment scale up.

Does nonlocal women's attendance at antenatal clinics distort HIV prevalence surveillance estimates in pregnant women in Zimbabwe?

OBJECTIVE

The objective was to assess whether HIV prevalence measured among women attending antenatal clinics (ANCs) are representative of prevalence in the local area, or whether estimates may be biased by some women's choice to attend ANCs away from their residential location. We tested the hypothesis that HIV prevalence in towns and periurban areas is underestimated in ANC sentinel surveillance data in Zimbabwe.

METHODS

National unlinked anonymous HIV surveillance was conducted at 19 ANCs in Zimbabwe in 2000, 2001, 2002, 2004, 2006, 2009, and 2012. This data was used to compare HIV prevalence and nonlocal attendance levels at ANCs at city, town, periurban, and rural clinics in aggregate and also for individual ANCs.

RESULTS

In 2000, HIV prevalence at town ANCs (36.6%, 95% CI 34.4-38.9%) slightly underestimated prevalence among urban women attending these clinics (40.7%, 95% CI 37.6-43.9%). However, there was no distortion in HIV prevalence at either the aggregate clinic location or at individual clinics in more recent surveillance rounds. HIV prevalence was consistently higher in towns and periurban areas than in rural areas. Nonlocal attendance was high at town (26-39%) and periurban (53-95%) ANCs but low at city clinics (<10%). However, rural women attending ANCs in towns and periurban areas had higher HIV prevalence than rural women attending rural clinics, and were younger, more likely to be single, and less likely to be housewives.

CONCLUSIONS

In Zimbabwe, HIV prevalence among ANC attendees provides reliable estimates of HIV prevalence in pregnant women in the local area.

Statistical models for incorporating data from routine HIV testing of pregnant women at antenatal clinics into HIV/AIDS epidemic estimates

OBJECTIVE

HIV prevalence data collected from routine HIV testing of pregnant women at antenatal clinics (ANC-RT) are potentially available from all facilities that offer testing services to pregnant women and can be used to improve estimates of national and subnational HIV prevalence trends. We develop methods to incorporate these new data source into the Joint United Nations Programme on AIDS Estimation and Projection Package in Spectrum 2017.

METHODS

We develop a new statistical model for incorporating ANC-RT HIV prevalence data, aggregated either to the health facility level (site-level) or regionally (census-level), to estimate HIV prevalence alongside existing sources of HIV prevalence data from ANC unlinked anonymous testing (ANC-UAT) and household-based national population surveys. Synthetic data are generated to understand how the availability of ANC-RT data affects the accuracy of various parameter estimates.

RESULTS

We estimate HIV prevalence and additional parameters using both ANC-RT and other existing data. Fitting HIV prevalence using synthetic data generally gives precise estimates of the underlying trend and other parameters. More years of ANC-RT data should improve prevalence estimates. More ANC-RT sites and continuation with existing ANC-UAT sites may improve the estimate of calibration between ANC-UAT and ANC-RT sites.

CONCLUSION

We have proposed methods to incorporate ANC-RT data into Spectrum to obtain more precise estimates of prevalence and other measures of the epidemic. Many assumptions about the accuracy, consistency, and representativeness of ANC-RT prevalence underlie the use of these data for monitoring HIV epidemic trends and should be tested as more data become available from national ANC-RT programs.