Thirty-two years into the HIV epidemic in the United States, women are increasingly represented among those diagnosed with HIV infection.1 Although women represented just 7% of US persons diagnosed with late-stage HIV infection in 1981, they accounted for 25% of persons with HIV diagnoses as of 2010.1 Among HIV-infected women, heterosexual activity is the main mode of transmission.1 Black/African American and Hispanic/Latina women are disproportionately affected, accounting for 57% and 16%, respectively, or 73% total, of women newly infected with HIV as of 2009.2 The majority of women living with HIV infection are diagnosed during their reproductive years (age, 15–45 years),1,3 yet HIV-infected women report that gender-specific discussions with their health care providers, including discussions of possible pregnancy intentions, contraception, and optimizing medical management if pregnancy is desired, are lacking.4–7
During the past 20 years, advances in HIV care and treatment have prolonged survival and contributed to significant reductions in perinatal, mother-to-child transmission of HIV infection,8 suggesting that elimination of perinatal HIV transmission may be a feasible goal. Challenges to further reduction of perinatal HIV transmission are largely due to inadequate or late access to HIV testing and insufficient or lack of antiretroviral treatment during the perinatal and postpartum periods.9,10 Globally, increased efforts are underway to further reduce perinatal HIV transmission in support of World Health Organization and US goals to move toward an HIV- and AIDS-free generation by 201511,12; reduction of unplanned pregnancies among women living with HIV infection is one of the 4 major World Health Organization strategies toward the goals of further reducing mother-to-child transmission of HIV and achieving an AIDS-free generation.11
Unplanned pregnancies comprise ∼50% of all pregnancies among the general US population of reproductive-age women13 and as much as 55%–65% of all pregnancies among HIV-infected women globally.14–16 Among HIV-infected adolescent women in the United States and Europe, estimates of unplanned pregnancies are as high as 83% and include adolescents who received HIV diagnoses during routine prenatal care and those who were aware of their infection before conception.17–19 Unplanned pregnancies contribute disproportionately to the remaining cases of perinatally infected children in the United States, and perinatal HIV infection continues to be a public health issue with substantial HIV-related racial/ethnic health disparities.20 However, estimates of unplanned pregnancies among HIV-infected US women across the reproductive span of 15–45 years and who are aware of their HIV diagnosis at the time of pregnancy have been understudied. These estimates represent gaps in our understanding about reproductive health care for women living with HIV infection. They also represent missed opportunities to ensure effective family planning, decrease unplanned pregnancies, further decrease perinatal transmission and HIV-related health disparities, and decrease possible sexual transmission of HIV infection that may occur during unprotected sexual intercourse. As women of color are disproportionately affected by HIV infection, by unplanned pregnancies, and by perinatal HIV infection, efforts with HIV-infected reproductive-aged women could greatly reduce this HIV-related health disparity and improve health outcomes for communities of color, consistent with the US National HIV/AIDS Strategy goals of reducing HIV incidence and reducing HIV-related health disparities.20–22
To examine the prevalence and sociodemographic and clinical correlates of unplanned pregnancies among HIV-infected women in care in the United States, we conducted an analysis of cross-sectional data from a sample of HIV-infected women diagnosed before age 45 years receiving HIV clinical care at medical facilities in the United States and Puerto Rico. These findings may be used to better understand and strengthen gender-specific, reproductive health HIV prevention interventions for women living with HIV infection.
This report describes a subanalysis of HIV-infected women enrolled in the Medical Monitoring Project (MMP). MMP is a cross-sectional, 3-stage probability-proportional-to-size sample of adults (aged ≥18 years) receiving HIV medical care. Detailed background and methods for MMP have been described previously.23–25 In brief, MMP samples from HIV-infected patients receiving outpatient HIV medical care. During the 2007 and 2008 MMP cycles (data collected through April 2009), 26 project areas collected data: California, Chicago (IL), Delaware, Florida, Georgia, Houston (TX), Illinois, Indiana, Los Angeles County (CA), Maryland, Massachusetts, Michigan, Mississippi, New Jersey, the state of New York, New York City, North Carolina, Oregon, Pennsylvania, Philadelphia (PA), Puerto Rico, San Francisco (CA), South Carolina, Texas, Virginia, and Washington state. The 2007–2008 MMP cycles are the most recent years for which detailed pregnancy data were collected.
MMP collects data using (1) an interview to collect behavioral and clinical information, (2) a medical record abstraction, and (3) a data extract from the local HIV surveillance system. Eligibility criteria for participation in MMP include diagnosis of HIV infection, ≥18 years of age, not a previous participant in MMP during the current data collection cycle, recipient of medical care between January and April of the data collection year at the facility, and ability to provide informed consent. For this pregnancy subanalysis, women were included if they had an HIV diagnosis before age 45 years, reported at least 1 pregnancy after learning of their HIV diagnosis, and indicated whether or not they were trying to get pregnant during any pregnancy after their HIV diagnosis.
All participating states or territories and facilities obtained local Institutional Review Board review and approval to conduct MMP, and all patients provided informed consent to participate.26,27 The average facility response rate for the combined 2007 and 2008 MMP data collection years was 83.9% (range, 60%–100%). The average patient response rate for the combined 2007 and 2008 MMP data collection years was 36.4% (range, 8%–72%). Overall, the average overall response rate (both facility-level and patient-level data were available) was 31% (range, 5%–68%).
MMP survey included questions about demographics, social factors, and self-reported clinical information, including date of birth, race/ethnicity, educational attainment, age at HIV diagnosis, age at MMP interview, country of birth, receipt of public assistance (past year), reason for getting tested when first diagnosed, number of previous live births (if any), any obstetrical and gynecological care (past year), ever told of an AIDS diagnosis, lowest ever CD4 T-lymphocyte count, use of antiretroviral medications (ever), injection drug use (ever), salary versus nonsalary wages (past year), safer sex conversations with health care provider (past year), any unprotected sex with sex partner of known or unknown HIV status (past year), numbers of sex partners (past year), and HIV status of current main sex partner. Women were asked about the number of pregnancies after learning of HIV diagnosis (“How many times have you been pregnant after you learned you had HIV?”), and whether or not they were trying to get pregnant for each pregnancy for the first through eighth pregnancies (“For each pregnancy after you learned you had HIV, were you trying to get pregnant?”).
For this subanalysis on unplanned pregnancy, the MMP self-reported interview data were used. The medical record abstraction and the minimum data elements from the local HIV surveillance were only used to provide the date of first positive HIV test. Women whose pregnancy status or intentions were unknown (n = 7) or who reported no pregnancies after receiving their HIV diagnosis (n = 1103) were excluded. For the remaining women who reported ≥1 pregnancy, we classified woman as having had an unplanned pregnancy, if after learning they were HIV-infected they had ≥1 unplanned pregnancy. Women who reported at least 1 unplanned pregnancy responded “no” to the question about trying to get pregnant with any reported pregnancy, and those who did not report any unplanned pregnancies responded “yes” to trying to get pregnant for each pregnancy. Total number of pregnancies and pregnancy outcomes were also reviewed for women who reported at least 1 pregnancy. We summarized demographic characteristics using medians and interquartile ranges (IQRs) for continuous variables; percentages were computed for categorical data. We tested for differences in the characteristics of women with any unplanned pregnancies compared with those who had no unplanned pregnancies using Pearson χ2 for categorical variables. For continuous variables, we used the Kruskal–Wallis χ2 test to compare medians between the groups.
We used logistic regression to calculate unadjusted and adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for correlates of unplanned pregnancies among women with ≥1 pregnancy after HIV diagnosis. Factors associated with having had an unplanned pregnancy at P < 0.10 were used for initial inclusion in the multivariate regression models. Final models were determined using backward stepwise regression with a P < 0.05 retention criteria and included variables associated with unplanned pregnancies based on literature reviews.14,15 We assessed model fit with the Hosmer and Lemeshow goodness-of-fit test with unplanned pregnancy as the outcome. We used SAS version 9.2 (SAS Institute, Cary, NC) for all analyses.
Of 1492 women who met inclusion criteria and had available data in the 2007–2008 MMP cycles, 382 (25.6%) reported ≥1 pregnancy after their HIV diagnosis (median diagnosis age at HIV diagnosis = 25.0 years; IQR = 21.0–30.0). These 382 women comprised the final sample for this analysis; 58% were non-Hispanic black, 22% Hispanic and 15% non-Hispanic white; the median age at MMP interview was 38.0 years (IQR = 31.0–43.0); median number of pregnancies was 1 (IQR = 1–2); 78% were born in the United States, and 61% were diagnosed with HIV ≥10 years before the date of interview. Table 1 summarizes additional demographic and social characteristics of the study population and differences in these characteristics between women with any versus no unplanned pregnancies.
Three hundred twenty-six (85.3%) of 382 women reported ≥1 unplanned pregnancy while aware of their HIV diagnosis, of whom the majority (56.1%) were in their twenties at the time of their HIV diagnosis: 25.5% were aged 20–24 years, and 26.1% were aged 25–29 years. Two hundred thirty (60.2%) women reported 1 pregnancy only, 102 (26.7%) reported 2 pregnancies, 32 (8.4%) women reported 3 pregnancies, and 18 (4.7%) women reported ≥4 pregnancies, which included both unplanned and planned pregnancies (Fig. 1). Unplanned pregnancies were prevalent among women across all age (ie, age at the time of HIV diagnosis) groups, with ≥80% of women in each age range reporting ≥1 unplanned pregnancy after being diagnosed with HIV (Fig. 2). Women with unplanned pregnancies did not differ significantly from HIV-infected women who reported no unplanned (all planned) pregnancies in terms of their median age at HIV diagnosis or number of pregnancies after HIV diagnosis. Only 56 (14.7%) of 382 women reported no unplanned (all planned) pregnancies.
There were 620 total pregnancies reported by women in this sample; 428 (69.0%) were among women who reported that all pregnancies were unplanned; 113 (18. 2%) were among women who reported a history of both planned and unplanned pregnancies. These 620 pregnancies resulted in 400 (64. 5%) live births, 133 (21.4%) abortions, 69 (11.1%) stillbirths, 6 (1.0%) outcomes were not reported, and 12 (1.9%) were active pregnancies at the time of the MMP interview (Fig. 3). The distribution of birth outcomes was similar for the 541 births among women with at least 1 unplanned pregnancy after HIV diagnosis. Abortions were not more likely among women with unplanned pregnancies in our sample. Among the reasons women reported for getting HIV tested when they were diagnosed, the most common were nonpregnancy related, routine screening, such as for a checkup, physical examination, or life insurance (33%), risk concerns, such as intravenous drug use, male-to-male sex behaviors, high-risk sex activity, or sex partner with those behaviors, sex partner or needle sharing partner was HIV positive, needle-stick follow-up, or other possible exposure (27%), and pregnancy-related/prenatal visit screenings (24%) (Table 1 and Fig. 4).
In the bivariate analyses, women born in the United States were more likely than women born outside of the United States to have an unplanned pregnancy. Also, women reporting CD4 cell counts <200 cells/μL [odds ratio (OR) = 2.4; 95% CI: 1.2 to 4.7] or not reporting any CD4 cell counts (OR = 3.1; 95% CI: 1.4 to 6.9) were more likely to report an unplanned pregnancy compared with women who reported CD4 cell counts ≥200 cells/μL. Women whose initial reason for getting an HIV test when they were first diagnosed was related to pregnancy/child outcome or a prenatal visit (OR = 3.0; 95% CI: 1.0 to 9.2), and women who received public assistance in the year before their MMP interview (OR = 1.8; 95% CI: 1.002 to 3.1) were also more likely to report an unplanned pregnancy compared with women who reported an initial HIV test for illness reasons and who did not receive public assistance, respectively.
In the multivariate analysis, unplanned pregnancies were significantly more likely among women who reported nadir CD4 cell counts <200 cells/μL (AOR = 2.3; 95% CI: 1.1 to 4.8) or did not report nadir CD4 cell counts (AOR = 4.3; 95% CI: 1.9 to 10.5) compared with women who reported nadir CD4 cell counts ≥200 cells/μL; whose reason for getting HIV tested when first diagnosed was related to pregnancy, recent childbirth, or prenatal visits (AOR = 3.8; 95% CI: 1.2 to 12.8) compared with women tested because of illness or HIV risk exposure concerns; who received public assistance in the past year compared with having not received such assistance (AOR = 2.1; 95% CI: 1.1 to 3.8); and who were interviewed closer to their date of HIV diagnosis (AOR = 1.4 per year after HIV diagnosis; 95% CI: 1.1 to 1.8). Age, race/ethnicity, and education level were not independently associated with unplanned pregnancies among women in our sample.
Of note, 187 (49%) women in our sample report having safer sex conversations with their health care provider at more than half of all visits in the 12 months before MMP interview (not significant in final model). However, 124 (33%) of our sample reported unprotected vaginal and/or anal sex with a male partner who was either HIV negative or had an unknown HIV status in the 12 months before MMP interview.
Unplanned pregnancies were prevalent among our sample of HIV-infected women of reproductive age who had at least 1 pregnancy after HIV diagnosis, with >85% reporting at least 1 unplanned pregnancy and 32.5% reporting unprotected vaginal and/or anal sex with a male partner of either negative or unknown HIV status. Unplanned pregnancies suggest episodes of vaginal sex without contraception, or with suboptimal contraceptive barriers, a known risk for HIV acquisition or transmission. This unplanned pregnancy rate is higher than unintended pregnancy rates described in other global reports of reproductive age women living with HIV infection14,28,29 but similar to the reported rate of 83.3% among HIV-infected adolescent women (aged <18 years).17 This report provides the first estimate for unplanned pregnancies among a sample of reproductive-age (15–45 years) US women living with HIV infection and engaged in care and shows that unplanned pregnancies for HIV-infected women are prevalent across the reproductive age span, from adolescence to maturity.
Most pregnancies (65%) among women in our sample resulted in live birth outcomes; about one-fifth of pregnancies resulted in an abortion; this was true also for the 541 pregnancies that were unplanned. The live birth outcomes suggest that routine reproductive counseling by providers for safe conception and decreased perinatal HIV transmission risk is warranted for women living with HIV and in clinical care.30–32 In addition, the abortion outcomes suggest that access to and utilization of effective contraceptives may be warranted for some of these women to maximize pregnancy options before having an unplanned pregnancy and therefore decrease abortions associated with some unplanned pregnancies.30–32
The majority (49%) of our study participants report safer sex conversations with their health care providers at over half of their clinical care visits during the year before the MMP interview, but details of those conversations and whether condoms or other specific contraceptives were discussed is unknown. Future studies should inquire about prevalence and types of safer sex discussions women have with their health care providers to learn important information about the content of the discussions, including condom use and condom negotiation discussions, reproductive health issues and which contraceptives are being used by women in HIV clinical care.33 Obtaining this information is particularly important for providers to assess in the setting of HIV care, where antiretroviral regimens may need to be reviewed and possibly revised to ensure compatibility with any contraceptives used.34 For women who may be newly considering conception, discussing pregnancy intentions is an important opportunity to review for any teratogenic effects of antiretroviral therapy regimens and plan for alternative treatment options, if needed.34 Recent studies suggest that these reproductive health discussions happen infrequently between providers and patients and should be strengthened, despite the stigma barriers.31,35,36 Clinical data suggest that important next steps are needed to make reproductive health discussions a component of routine care for HIV-infected women, including incorporation of provider trainings into medical education curricula, updating clinical practice guidelines, and standardizing counseling and/or referrals to systematize providers' assessments of reproductive desires.31,36
In our model, significant correlates of unplanned pregnancy for HIV-infected women in care included ever having a CD4 count nadir < 200 cells/μL, consistent with an AIDS diagnosis, and having recently received public assistance. These findings may represent barriers with timely access to HIV diagnosis and care, which remain a challenge for blacks/African Americans and Hispanics/Latinos compared with other groups37 and minority women.38 Although it is not possible with this cross-sectional retrospective analysis to know if social or structural barriers directly impacted access to care or progression to AIDS for women in our sample, other studies have documented social and structural access challenges for women that negatively affect their HIV care and clinical outcomes, especially for black/African American and Hispanic/Latina women.21,38 Improved health care access with the Affordable Care Act is expected to help persons living with HIV infection.39 Particularly for minority and underserved women living with HIV infection and decreased health care access, the Affordable Care Act may allow important new opportunities to access to both HIV and reproductive health care, including contraception.40 We also suggest social and structural interventions that increase access to acceptable and culturally relevant care for disproportionately affected women of color to help close these racial/ethnic HIV disease–related access and care gaps, consistent with National HIV/AIDS Strategy goals.
Several study limitations are noted. First, HIV-infected women who are not in care are not included in this sample; we are unable to assess the prevalence or characteristics of HIV-infected women not in care who had unplanned pregnancies. Second, the MMP response rates were suboptimal for study participants at the participating facilities; this sample might not be representative of all persons engaged in HIV clinical care and those unengaged in HIV clinical care. Third, recall bias was possible as participants were asked to report on several pregnancy-related details that were often more than 1 year in the past. In addition, family planning and contraceptive data were not available during the 2007–2008 MMP cycles; it is not possible to know what proportion of women in our sample may have been using contraceptives to prevent unplanned pregnancies. Thus, the volume of possible contraceptive failure that may have contributed to the unplanned pregnancies is unknown. Fourth, social desirability bias may have limited participants' disclosure about sensitive topics, such as pregnancy desires and outcomes. Finally, these data were not weighted to provide national estimates; MMP data cycles after 2009 will be weighted for nationally representative estimates.
Our study findings underscore that efforts to decrease unplanned pregnancies among HIV-infected women are warranted. Multiple, unplanned pregnancies while already HIV-infected suggest missed opportunities for reproductive health dialogue with providers. Although for some women living with HIV infection multispecialty care is the norm to facilitate medical management of comorbidities, for many, care is strengthened by a single provider approach, which streamlines HIV medical management and obstetrical/gynecological care to occur with 1 facility/provider.41 This streamlined approach often decreases multiple visits for women, increases compliance with follow-up recommendations, and improves the ability of providers to review for possible medication interactions.41 Cross training providers in both HIV care and gynecologic care may help ensure reproductive health dialog occurs during clinical visits. These discussions and access to safe and effective family planning options will help ensure that HIV-infected women have well-timed, planned pregnancies (if desired) and decreased perinatal and sexual transmission risk.
Unprotected sex and unintended pregnancies among HIV-infected women remain public health challenges; they increase the risk of sexual and vertical transmission of HIV, respectively, and hamper efforts to reduce perinatal HIV transmission and achieve global elimination for an AIDS-free generation. Creative solutions to reduce these challenges will have huge implications for reducing HIV-related health disparities and improving health equity, consistent with national HIV prevention and health promotion goals.
The authors thank all participating MMP patients, staff members, and facilities in the 26 US health jurisdictions.
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