Effect of Pregnancy on Response to Antiretroviral Therapy in HIV-infected African women.

Publication Type:

Journal Article


Journal of acquired immune deficiency syndromes (1999) (2016)


BACKGROUND: While most recent evidence does not support a role for pregnancy in accelerating HIV disease progression, very little information is available on the effects of incident pregnancy on response to antiretroviral therapy (ART). Hormonal, immune and behavioral changes during pregnancy may influence response to ART. We sought to explore the effects of incident pregnancy (after ART initiation) on virologic, immunologic, and clinical response to ART.

METHODS: Data were collected from HIV-infected women participating in 3 prospective studies (Partners in Prevention HSV/HIV Transmission Study, Couples Observational Study, and Partners PrEP Study) from seven countries in Africa from 2004 to 2012. Women were included in this analysis if they were ≤ 45 years of age, were started on ART during the study and were not pregnant at ART initiation. Pregnancy was treated as a time-dependent exposure variable covering the duration of pregnancy, including all pregnancies occurring after ART initiation. Virologic failure was defined as a viral load (VL) greater than 400 copies/ml ≥6 months after ART initiation and viral suppression was defined as viral load ≤400 copies/ml. Multivariable Cox proportional hazards models were used to assess the association between pregnancy and time to viral suppression, virologic failure, WHO clinical stage III/IV and death. Linear mixed effects models were used to assess the association between pregnancy and CD4+ count and VL. All analyses were adjusted for confounders, including pre-ART CD4+ count and plasma VL.

RESULTS: A total of 1041 women were followed, contributing 1196.1 person-years of follow-up. Median CD4+ count prior to ART initiation was 276 cells/mm (IQR, 209-375); median pre-ART VL was 17,511 copies/ml (IQR, 2,480-69,286). One-hundred ten women became pregnant after ART initiation. Pregnancy was not associated with time to viral suppression (adjusted HR, 1.20, 95% CI, 0.82-1.77), time to virologic failure (adjusted HR, 0.67, 95% CI, 0.37-1.22), time to WHO clinical stage III or IV (adjusted HR, 0.79, 95% CI, 0.19-3.30) or time to death (adjusted HR, 2.04, 95% CI, 0.25-16.8). Incident pregnancy was associated with an adjusted mean decrease in CD4+ T cell count of 47.3 cells/mm (p<0.001), but not with difference in VL (p=0.06).

CONCLUSIONS: For HIV-infected women on ART, incident pregnancy does not affect virologic control or clinical HIV disease progression. A modest decrease in CD4+ T cell count could be due to physiologic effects of pregnancy.