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Prevalent Pregnancy, Biological Sex, and Virologic Response to Antiretroviral Therapy

Westreich, Daniel PhD*; Evans, Denise PhD†,‡; Firnhaber, Cindy MD, MS†,§; Majuba, Pappie MBChB§; Maskew, Mhairi MBBCh, MSc†,‡

JAIDS Journal of Acquired Immune Deficiency Syndromes: August 15th, 2012 - Volume 60 - Issue 5 - p 489–494
doi: 10.1097/QAI.0b013e318256b310
Epidemiology and Prevention

Objective: Pregnancy is a common indication for initiation of highly active antiretroviral therapy (HAART) in sub-Saharan Africa. Our objective was to evaluate how pregnancy at treatment initiation predicts virologic response to HAART.

Methods: We evaluated an open cohort of 9173 patients who initiated HAART between April 2004 and September 2009 in the Themba Lethu Clinic in Johannesburg, South Africa. Risk ratios were estimated using log-binomial regression; hazard ratios were estimated using Cox proportional hazards models; time ratios were estimated using accelerated failure time models. We controlled for calendar date, age, ethnicity, employment status, history of smoking, tuberculosis, WHO stage, weight, body mass index, hemoglobin, CD4 count and CD4 percent, and whether clinical care was free. Extensive sensitivity and secondary analyses were performed.

Results: During follow-up, 822 nonpregnant women and 70 pregnant women experienced virologic failure. In adjusted analyses, pregnancy at baseline was associated with reduced risk of virologic failure by 6 months [risk ratio 0.66, 95% confidence limits (CL): 0.35 to 1.22] and with reduced hazard of virologic failure over follow-up (hazard ratio: 0.69, 95% CL: 0.50 to 0.95). The adjusted time ratio for failure was 1.44 (95% CL: 1.13 to 1.84), indicating 44% longer time to event among women pregnant at baseline. Sensitivity analyses generally confirmed main findings.

Conclusions: Pregnancy at HAART initiation is not associated with increased risk of virologic failure at 6 months or during longer follow-up.

*Department of Obstetrics and Gynecology and Duke Global Health Institute, Duke University, Durham, NC

Department of Medicine, Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa

Department of Medicine, Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

§Right to Care, Johannesburg, South Africa.

Correspondence to: Daniel Westreich, PhD, Department of Obstetrics and Gynecology, Duke University Medical Center, Box 3084, Med Center, Durham, NC 27710 (e-mail:

The clinical activities of the Helen Joseph Hospital are supported by the National and Gauteng Department of Health and the United States President's Emergency Plan for AIDS Relief in a grant by USAID to Right to Care and the Institution (674-A-00-08-00007-00). The research activities of this publication are supported by the National Institutes of Health in a grant from the Eunice Kennedy Shriver NICHD 4R00-HD-06-3961-03 and National Institute of Allergy and Infectious Diseases 2P30-AI064518-06 Duke Center for AIDS Research. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the article.

This research was declared exempt from review by both the University of the Witwatersrand and Duke University.

The authors have no conflicts of interest to disclose.

Received December 1, 2011

Accepted March 19, 2012

© 2012 Lippincott Williams & Wilkins, Inc.