PREGNANCY OUTCOMES AMONG HIV-INFECTED WOMEN IN UGANDA AND ZIMBABWE

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1 PREGNANCY OUTCOMES AMONG HIV-INFECTED WOMEN IN UGANDA AND ZIMBABWE Kathryn Lancaster, MPH 3rd International Workshop on HIV & Women January 15, 2013

2 HIV among women of reproductive age Women of reproductive age (18-49 years) make up approximately 46% of the world s HIV infections (Sources: UNAIDS 2006) In sub-saharan Africa women bear the largest burden of HIV (Sources: UNAIDS, 2009; Mepham, 2009) Fertility desires among HIV infected women are high (source: Nakayiwa, 2006) 18% of HIV infected Ugandan women have desire for more children Associated factors include young age, number of living children, and thought that HIV+ women should have children High unmet need for contraception in HIV infected women (source: Jhangri, 2011)

3 HIV and pregnancy outcomes Early studies from sub-saharan Africa suggests that HIV infection leads to adverse pregnancy outcomes Low birth weight Perinatal and neonatal death These studies were limited by their lack of HIV specificdata, like CD4 counts, and their inability to follow pregnancies prospectively Need for further evidence on pregnancy outcomes and associated factors, particularily in high HIV prevalence settings

4 Study Population FHI 360: Hormonal Contraception and HIV Genital Shedding & Disease Progression Study, HIV infected women Recruited from family planning sites in Uganda and Zimbabwe years Known seroconversion dates Hormonal contraceptive use

5 Study procedures Women were examined quarterly Received urine Hcg testing for incident pregnancies Pregnancy outcomes recorded Kaplan-Meier method was used to estimate pregnancy probabilities Logistic regressions with Generalized Estimating Equations to evaluate factors associated with birth outcomes

6 Characteristics of HIV positive women at enrollment Characteristic Uganda (n=127) n (%) or Median (Q1-Q3) Zimbabwe (n=179) n (%) or Median (Q1-Q3) Total (n=306) n (%) or Median (Q1-Q3) p-value 1 Age at estimated infection date 26 (23-30) 26 (23-30) 26 (23-30) 0.79 Living with partner 2 74 (58) 126 (70) 200 (65) 0.03 Number of years in school 3 8 (6-10) 11 (9-11) 10 (7-11) <.01 Age at first pregnancy 26 (24-28) 26 (24-30) 26 (24-29) 0.88 CD ( ) 495 ( ) ( ) <.01 1 Chi-square test for categorical variables and Wilcoxon Mann Whitney test for continuous variables 2 at GS enrollment visit 3 at HC screening visit

7 Number of pregnancies 1,2 and rate by HAART use Time 3 without HAART usage Time with HAART usage 4 Total Study Sties N/wy (incidence rate per 100wy) N/wy (incidence rate per 100wy) N/wy (incidence rate per 100wy) p-value Uganda 78/513 (15.2) 4/56 (7.2) 82/569 (14.4) 0.14 Zimbabwe 72/887 (8.1) 6/128 (4.7) 78/1014 (7.7) 0.23 Total 150/1400 (10.7) 10/183 (5.5) 160/1583 (10.1) multiple pregnancies per woman are included 2 13 pregnancies are excluded as the start date of pregnancy was before the estimated infection date 3 estimated HIV infection date 4 HAART used at the start date of pregnancy

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9 Pregnancy and delivery characteristics in HIV positive women 40 (54%) of pregnancies in Uganda and 46 (68%) pregnancies in Zimbabwe received antenatal care Median month received care was month 5 (IQR: 4-7) in both countries A total of 26 (18%) reported maternal illness during pregnancy and 18 (13%) reported pregnancy complications Delivery occurred at 37+ weeks for 34 (45%) pregnancies in Uganda and 43 (56%) pregnancies All births were vaginal deliveries, with the exception of 10 (11%) Cesarean deliveries, 8 in Uganda and 2 in Zimbabwe

10 Pregnancy outcomes in HIV positive women 1 Characteristic Uganda (n=82) n (%) Zimbabwe (n=78) n (%) Total (n=160) n (%) p-value 2 Pregnancy Outcome Live birth 42 (51) 52 (67) 94 (59) Fresh stillbirth 1 (1) 3 (4) 4 (3) Miscarriage 13 (16) 14 (18) 27 (17) Induced abortion 22 (27) 5 (7) 27 (17) Unknown 4 (5) 4 (5) 8 (5) <0.01 Birth Weight >=2.5kg 38 (46) 39 (50) 77 (48) <2.5kg 3 (4) 9 (12) 12 (8) Unknown 41 (50) 30 (38) 71 (44) Multiple pregnancies per woman allowed 2 Chi-square or Exact test for categorical variables and Wilcoxon Mann Whitney test for continuous variables

11 Factors associated with live birth among HIV positive women Bivariate analysis Full multivariate Final multivariate Variable OR (95% CI) p- value OR (95% CI) p- value OR (95% CI) p- value HAART use during pregnancy 5.4 (0.6, 45.1) (1.2, 194.1) (0.8, 83.9) 0.08 Antenatal care 71.9 (20.3, 255.2) < (24.5, ) < (26.0, 594.4) <.01 Illness during pregnancy 0.3 (0.1, 0.7) (0.0, 0.5) < (0.0, 0.7) 0.01 Pregnancy complications 0.2 (0.1, 0.7) (0.1, 7.3) Baseline CD4: <350 cells 1.4 (0.3, 6.3) (0.5, 12.3) Baseline CD4: cells 0.9 (0.4, 2.5) (0.4, 2.4) Age at labor: (0.8, 6.7) (0.7, 45.6) Age at labor: (0.8, 5.6) (0.6, 19.8)

12 In summary Pregnancy incidence rate was higher (p = 0.04) among HAART-naïve women at 10.7 per 100wy than among women taking HAART (5.5 per 100wy) Most pregnancies of the HIV infected women were likely to receive antenatal care, deliver at 37+ weeks, have a live birth, and have infant with normal birth weight (>=2.5kg) Antenatal care, HAART use, and lack of illness during pregnancy are associated with live birth among HIV positive women

13 Considerations Strengths Women were followed for up to 9 years following HIV infection Detection and follow up of incident pregnancies Well timed estimated dates of HIV seroconversion Limitations Few HIV positive women had at previously initiated HAART at time of pregnancy Infants were not followed and therefore unable to determine HIV status and other adverse health outcomes related to pregnancy

14 The way forward Services should target HIV positive women to address their fertility issues, regardless of HAART status Emphasize need for timely and appropriate antenatal care and monitoring of pregnancy complications and illnesses for HIVinfected women Strengthened antenatal care services should be rapidly integrated with prevention of mother-to-child transmission services in high HIV prevalence settings Women living with HIV require strongly linked services addressing fertility-related issues to optimize health outcomes for mother and baby

15 Acknowledgements FHI 360, Durham, NC, USA Dr. Charles Morrison Dr. Pai Lien Chen Ms. Cynthia Kwok Ms. Anne Rinaldi Makerere University, Kampala, Uganda Dr. Josaphat Byamugisha University of Zimbabwe, Harare, Zimbabwe Dr. Thulani Magwali Ms. Prisca Nyamapfeni Case Western Reserve University, Cleveland, OH, USA Dr. Robert Salata GS study participants from Uganda and Zimbabwe This project has been funded with FHI 360.