Increase in pregnancy rates in west Africa after initiation of antiretroviral therapy

Incidence of pregnancy after antiretroviral therapy initiation and associated factors in 8 West African countries.

Burgos-Soto J, Balestre E, Minga A, Ajayi S, Sawadogo A, Zannou MD, Leroy V, Ekouevi DK, Dabis F, Becquet R, IeDEA West Africa Collaboration. J Acquir Immune Defic Syndr. 2014 Oct 1;67(2):e45-54. doi: 10.1097/QAI.0000000000000279.

Introduction: This study aimed at estimating the incidence of pregnancy after antiretroviral therapy (ART) initiation in 8 West African countries over a 10-year period.

Methods: A retrospective analysis was conducted within the international database of the IeDEA West Africa Collaboration. All HIV-infected women aged <50 years and starting ART for their own health between 1998 and 2011 were eligible. Pregnancy after ART initiation was the main outcome and was based on clinical reporting. Poisson regression analysis accounting for country heterogeneity was computed to estimate first pregnancy incidence post-ART and to identify its associated factors. Pregnancy incidence rate ratios were adjusted on country, baseline CD4 count and clinical stage, hemoglobin, age, first ART regimen, and calendar year.

Results: Overall, 29 425 HIV-infected women aged 33 years in median (interquartile range, 28-38) contributed for 84 870 woman-years of follow-up to this analysis. The crude incidence of first pregnancy (2304 events) was 2.9 per 100 woman-years [95% confidence interval (CI): 2.7 to 3.0], the highest rate being reported among women aged 25-29 years: 4.7 per 100 woman-years; 95% CI: 4.3 to 5.1. The overall Kaplan-Meier probability of pregnancy occurrence by the fourth year on ART was 10.9% (95% CI: 10.4 to 11.4) and as high as 28.4% (95% CI: 26.3 to 30.6) among women aged 20-29 years at ART initiation.

Conclusions: The rate of pregnancy occurrence after ART initiation among HIV-infected women living in the West Africa region was high. Family planning services tailored to procreation needs should be provided to all HIV-infected women initiating ART and health consequences carefully monitored in this part of the world.

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Editor’s notes: Women of reproductive age are the largest population affected by HIV infection in sub-Saharan Africa. The wide availability of antiretroviral therapy (ART) has considerably decreased morbidity and mortality among women living with HIV. In addition, the risk of mother-to-child transmission of HIV has also been reduced. The authors hypothesised that the improvement in life expectancy is positively associated with procreation desires and fertility rates observed after ART initiation in several other settings. To test this hypothesis, they conducted a retrospective analysis using data from the International epidemiological Database to Evaluate AIDS (IeDEA). They found that the incidence of pregnancy was high after ART initiation among women living with HIV, although it was lower than among women without HIV in the same countries (four to six livebirths per 100 woman-years). The incidence rate of pregnancy increased slightly but progressively throughout years on ART, suggesting a positive effect of ART on fertility among women of reproductive age, particularly among young women. The authors suggest some biological mechanisms for the effect of ART on fertility. Further research in this area would be useful. Further, there is a large unmet need for family planning among women in west Africa, resulting in high rates of unintended pregnancies. This study highlights the need to understand the dynamics of fertility among women on ART, which is key to informing strategies integrating family planning into HIV care.

 
Africa
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