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HIV-infected women on antiretroviral treatment have increased mortality during pregnant and postpartum periods

Matthews, Lynn T.a,b; Kaida, Angelac; Kanters, Stevene; Byakwagamd, Helend,f; Mocello, A. Raind; Muzoora, Conradf; Kembabazi, Annetf; Haberer, Jessica E.g; Martin, Jeffrey N.d,h; Bangsberg, David R.a,f; Hunt, Peter W.h

doi: 10.1097/QAD.0000000000000040
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Objective: To assess the impact of pregnancy on mortality among HIV-infected Ugandan women initiating ART.

Design: Prospective cohort study.

Methods: HIV-infected women initiating ART in the Uganda AIDS Rural Treatment Outcomes study were assessed quarterly for self-reported pregnancy. The association between pregnancy and postpartum (‘pregnancy-related’) follow-up periods and mortality was assessed with Cox proportional hazards models adjusted for age, CD4 cell count, plasma HIV-1 RNA levels, and ART duration.

Results: Three hundred and fifty-four women with median age 33 years (IQR: 27–37) and CD4 142 cells/μl (IQR: 82–213) were followed for a median of 4.0 years (IQR: 2.5–4.8) after ART initiation, with 3 and 7% loss-to-follow-up at years 1 and 5. One hundred and nine women experienced pregnancy. Five deaths occurred during pregnancy-related follow-up and 16 during nonpregnancy-related follow-up, for crude mortality rates during the first year after ART initiation of 12.57/100 PYs and 3.53/100 PYs (rate ratio 3.56, 95% CI: 0.97–11.07). In adjusted models, the impact of pregnancy-related follow-up on mortality was highest at ART initiation (aHR: 21.48, 95% CI: 3.73–123.51), decreasing to 13.44 (95% CI 3.28–55.11) after 4 months, 8.28 (95% CI 2.38–28.88) after 8 months, 5.18 (95% CI: 1.36–19.71) after 1 year, and 1.25 (95% CI: 0.10–15.58) after 2 years on ART. Four of five maternal deaths occurred postpartum.

Conclusion: Pregnancy and the postpartum period were associated with increased mortality in HIV-infected women initiating ART, particularly during early ART. Contraception proximate to ART initiation, earlier ART initiation, and careful monitoring during the postpartum period may reduce maternal mortality in this setting.

aDivision of Infectious Disease, Massachusetts General Hospital, Center for Global Health

bDivision of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts

cSimon Fraser University, Faculty of Health Sciences, Burnaby, Canada

dDepartment of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, California

eUniversity of British Columbia, School of Population and Public Health, Vancouver, Canada

fMbarara University of Science and Technology, Mbarara, Uganda

gDepartment of Medicine, Massachusetts General Hospital, Center for Global Health, Boston, Massachusetts

hUniversity of California at San Francisco, Department of Medicine, San Francisco, California, USA.

Correspondence to Lynn T. Matthews, MD, MPH, Massachusetts General Hospital, Center for Global Health, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA. E-mail:

© 2013 Lippincott Williams & Wilkins, Inc.