Incidence of Pregnancy After Antiretroviral Therapy Initiation and Associated Factors in 8 West African Countries

Abstract

Introduction This study aimed at estimating the incidence of pregnancy after antiretroviral therapy (ART) initiation in eight 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, haemoglobin, age, first ART regimen and calendar year. Results Overall 29,425 HIV-infected women aged 33 years in median [Inter Quartile Range: 28–38] contributed for 84,870 women-years of follow-up to this analysis. The crude incidence of first pregnancy (2,304 events) was 2.9 per 100 women-years [95% confidence interval [CI]: 2.7–3.0], the highest rate being reported among women aged 25–29 years: 4.7 per 100 women-years; 95% CI: 4.3–5.1. The overall Kaplan-Meier probability of pregnancy occurrence by the fourth year on ART was 10.9% (95% CI: 10.4–11.4) and as high as 28.4% (95% CI: 26.3–30.6) among women aged 20–29 years at ART initiation. Conclusion 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.

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

“…This study from Johannesburg, South Africa found that pregnancy incidence increased among women on ART when their CD4 count was >100 cells/mm 3 and with better adherence . The finding of this study is consistent with two others that found pregnancy incidence to be significantly higher among women who started ART at WHO Stage 1/2 rather than WHO Stage 3/4 .…”

“…One study from rural Uganda found that pregnancy incidence peaked 12–18 months after initiation , while another study from rural Uganda found peaks at 6–12 months and then again at 4 years, presumably due to a birth interval effect . In West Africa, data from ART clinics in six countries showed the highest pregnancy incidence in year four . In contrast, a study from Johannesburg, South Africa found no difference in pregnancy incidence by time on ART .…”

“…Most studies were from a single setting, although five used data from multiple countries in the region . Data came from Uganda (9 studies), South Africa (4), Kenya (4), Malawi (2), Rwanda (2), Cote d'Ivoire (2), Zimbabwe (2), Zambia (1), Tanzania (1), Gambia (1), Mali (1), Guinea‐Bissau (1), Nigeria (1), Burkina Faso (1), Benin (1) and Senegal (1).…”

“…The study using clinical cohort data from six West African countries found that overall pregnancy incidence of women on ART increased over the time period (1998–2011). After adjusting for age, CD4 count, WHO clinical stage and haemoglobin at initiation, women who began ART between 2009 and 2011 had a 58% (95% CI 35–86) higher pregnancy incidence than women who began ART before 2005.…”

Decreasing incidence of pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya between 2005 and 2017: A retrospective cohort study.

“…This decreasing incidence rate is in contrast to a recent study of HIV positive women in Uganda, aged15-49, which showed an increase in pregnancy rates from 29.8 to 122 per 1000 woman years between 2006 and 2010[26]. This study, and others[27][28][29][30], have shown increased pregnancy incidence with engagement in care and/or initiation of ART. In women of reproductive age who are not adolescents, this may be a positive trend, demonstrating better control of HIV and ability to conceive.…”