Pregnancy and HIV Disease Progression during the Era of Highly Active Antiretroviral Therapy

Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
The Journal of Infectious Diseases (Impact Factor: 6). 11/2007; 196(7):1044-52. DOI: 10.1086/520814
Source: PubMed


Before the availability of highly active antiretroviral therapy (HAART), there was no clear effect of pregnancy on human immunodeficiency virus (HIV) disease progression. This has not been assessed during the HAART era.
We conducted an observational cohort study among HIV-infected women with >or=1 outpatient clinic visit between January 1997 and December 2004. HIV disease progression was defined as the occurrence of an AIDS-defining event or death.
Of 759 women who met the inclusion criteria, 139 (18%) had had >1 pregnancy, and 540 (71%) had received HAART. There was no difference in HAART duration by pregnancy status. Eleven pregnant (8%) and 149 nonpregnant (24%) women progressed to AIDS or death. After controlling for age, baseline CD4(+) lymphocyte count, baseline HIV-1 RNA level, and durable virologic suppression in a Cox proportional hazards model that included propensity score for pregnancy, pregnancy was associated with a decreased risk of disease progression (hazard ratio [HR], 0.40 [95% confidence interval {CI}, 0.20-0.79]; P=.009]). In a matched-pair analysis of 81 pregnant women matched to 81 nonpregnant women according to age, baseline CD4(+) lymphocyte count, receipt of HAART, and date of cohort entry, pregnant women had a lower risk of disease progression both before (HR, 0.10 [95% CI, 0.01-0.89]; P=.04) and after (HR, 0.44 [95% CI, 0.19-1.00]; P=.05) the pregnancy event.
Pregnancy was associated with a lower risk of HIV disease progression in this HAART-era study. This finding could be the result of the healthier immune status of women who become pregnant or could possibly be related to a beneficial interaction between pregnancy and HAART.

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Available from: Cornelia R Graves, Jan 04, 2016
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    • "Including pregnant women in non-pregnancy specific studies and assessing pregnancy as an exposure is important as pregnancy may influence HIV-related outcomes through hormonal, immunological or other physiological changes to the female body, or by altering drug pharmacokinetics [14,15]. Research around the impact of pregnancy on HIV progression and survival has produced varied findings [16–18]. Other studies have suggested that women are more susceptible to HIV-infection during pregnancy, as well as more likely to transmit HIV to partners [19,20]. "
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    ABSTRACT: HIV-related outcomes may be affected by biological sex and by pregnancy. Including women in general and pregnant women in particular in HIV-related research is important for generalizability of findings. To characterize representation of pregnant and non-pregnant women in HIV-related research conducted in general populations. All HIV-related articles published in fifteen journals from January to March of 2011. We selected the top five journals by 2010 impact factor, in internal medicine, infectious diseases, and HIV/AIDS. HIV-related studies reporting original research on questions applicable to both men and women of reproductive age were considered; studies were excluded if they did not include individual-level patient data. Articles were doubly reviewed and abstracted; discrepancies were resolved through consensus. We recorded proportion of female study participants, whether pregnant women were included or excluded, and other key factors. In total, 2014 articles were published during this period. After screening, 259 articles were included as original HIV-related research reporting individual-level data; of these, 226 were determined to be articles relevant to both men and women of reproductive age. In these articles, women were adequately represented within geographic region. The vast majority of published articles, 183/226 (81%), did not mention pregnancy (or related issues); still fewer included pregnant women (n=33), reported numbers of pregnant women (n=19), or analyzed using pregnancy status (n=9). Data were missing for some key variables, including pregnancy. The time period over which published works were evaluated was relatively short. The under-reporting and inattention to pregnancy in the HIV literature may reduce policy-makers' ability to set evidence-based policy around HIV/AIDS care for pregnant women and women of child-bearing age.
    Full-text · Article · Aug 2013 · PLoS ONE
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    • "As HIV care and treatment access continues to expand, people living with HIV/AIDS (PLHIV) are living longer and healthier lives. For the PLHIV whose health has been restored their concerns are shifting from ill health and medications to achieving full integration into communities and living a productive life, including having children [1,2]. In Africa, studies have documented societal expectations in relation to childbearing, specifically, pressures to have children, the need to have boys as heirs, and large families [3,4]. "
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    ABSTRACT: Background Some people living with HIV/AIDS (PLHIV) want to have children while others want to prevent pregnancies; this calls for comprehensive services to address both needs. This study explored decisions to have or not to have children and contraceptive preferences among PLHIV at two clinics in Uganda. Methods This was a qualitative cross-sectional study. We conducted seventeen focus group discussions and 14 in-depth interviews with sexually active adult men and women and adolescent girls and boys, and eight key informant interviews with providers. Overall, 106 individuals participated in the interviews; including 84 clients through focus group discussions. Qualitative latent content analysis technique was used, guided by key study questions and objectives. A coding system was developed before the transcripts were examined. Codes were grouped into categories and then themes and subthemes further identified. Results In terms of contraceptive preferences, clients had a wide range of preferences; whereas some did not like condoms, pills and injectables, others preferred these methods. Fears of complications were raised mainly about pills and injectables while cost of the methods was a major issue for the injectables, implants and intrauterine devices. Other than HIV sero-discordance and ill health (which was cited as transient), the decision to have children or not was largely influenced by socio-cultural factors. All adult men, women and adolescents noted the need to have children, preferably more than one. The major reasons for wanting more children for those who already had some were; the sex of the children (wanting to have both girls and boys and especially boys), desire for large families, pressure from family, and getting new partners. Providers were supportive of the decision to have children, especially for those who did not have any child at all, but some clients cited negative experiences with providers and information gaps for those who wanted to have children. Conclusions These findings show the need to expand family planning services for PLHIV to provide more contraceptive options and information as well as expand support for those who want to have children.
    Full-text · Article · Feb 2013 · BMC Public Health
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    • "Similarly, in the ANRS CO8 (APROCO-COPILOTE) study in France, among women on ART, pregnancy did not affect their long-term immunological and virological response (Le Moing et al. 2008). In a study in the USA, pregnancy in the ART era was associated with a significantly lower risk of HIV clinical disease progression, and the association persisted even after controlling for factors known to affect HIV disease progression, such as age, baseline CD4 cell counts, HIV RNA viral loads and duration on ART (Tai et al. 2007). As the main risk factor for mother-to-child transmission of HIV infection is maternal viral load (Arvold et al. 2007; Garcia et al. 1999; Mofenson et al. 1999), the finding that pregnancy had no negative effect on the virological outcome of ART is important for HIV-infected mothers receiving ART in sub-Saharan Africa who may wish to have children. "
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    ABSTRACT: Objectives  Before antiretroviral therapy (ART) introduction, pregnancy was associated with a sustained drop in CD4 cell count in HIV-infected women. We examined the effects of pregnancy on immunological and virological ART outcomes. Methods  Between January 2004 and March 2009, we studied HIV-infected women receiving ART in a prospective open cohort study in rural Uganda. We used random effects regression models to compare the CD4 counts of women who became pregnant and those who did not, and among the pregnant women before and after pregnancy. CD4 count and proportions with detectable viral load (≥400 copies/ml) were compared between the two groups using the Mann-Whitney rank sum test and logistic regression respectively. Results  Of 88 women aged 20-40 years receiving ART, 23 became pregnant. At ART initiation, there were no significant differences between those who became pregnant and those who did not in clinical, immunological and virological parameters. Among women who became pregnant, CD4 cell count increased before pregnancy (average 75.9 cells/mm(3) per year), declined during pregnancy (average 106.0) but rose again in the first year after delivery (average 88.6). Among women who did not become pregnant, the average CD4 cell count rise per year for the first 3 years was 88.5. There was no significant difference in the proportions of women with detectable viral load at last clinic visit among those who became pregnant (8.7%) and those who did not (16.1%), P = 0.499. Conclusion  Pregnancy had no lasting effect on the immunological and virological outcomes of HIV-infected women on ART.
    Full-text · Article · Dec 2011 · Tropical Medicine & International Health
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