title: High incidence of unplanned pregnancy after antiretroviral therapy initiation: findings from a prospective cohort study in South Africa.
abstract: BACKGROUND
  Increased fertility rates in HIV-infected women receiving antiretroviral therapy (ART) have been attributed to improved immunological function; it is unknown to what extent the rise in pregnancy rates is due to unintended pregnancies.
  
  
  METHODS
  Non-pregnant women ages 18-35 from four public-sector ART clinics in Johannesburg, South Africa, were enrolled into a prospective cohort and followed from August 2009-March 2011. Fertility intentions, contraception and pregnancy status were measured longitudinally at participants' routine ART clinic visits.
  
  
  RESULTS
  Of the 850 women enrolled, 822 (97%) had at least one follow-up visit and contributed 745.2 person-years (PY) at-risk for incident pregnancy. Overall, 170 pregnancies were detected in 161 women (incidence rate [IR]: 21.6/100 PY [95% confidence interval (CI): 18.5-25.2]). Of the 170 pregnancies, 105 (62%) were unplanned. Unmet need for contraception was 50% higher in women initiating ART in the past year as compared to women on ART>1 year (prevalence ratio 1.5 [95% CI: 1.1-2.0]); by two years post-ART initiation, nearly one quarter of women had at least one unplanned pregnancy. Cumulative incidence of pregnancy was equally high among recent ART initiators and ART experienced participants: 23.9% [95% CI: 16.4-34.1], 15.9% [12.0-20.8], and 21.0% [16.8-26.1] for women on ART 0-1 yr, >1 yr-2 yrs, and >2 yrs respectively (log-rank, p = 0.54). Eight hormonal contraceptive failures were detected [IR: 4.4 [95% CI: 2.2-8.9], 7/8 among women using injectable methods. Overall 47% (80/170) of pregnancies were not carried to term.
  
  
  CONCLUSIONS
  Rates of unintended pregnancies among women on ART are high, including women recently initiating ART with lower CD4 counts and higher viral loads. A substantial burden of pregnancy loss was observed. Integration of contraceptive services and counselling into ART care is necessary to reduce maternal and child health risks related to mistimed and unwanted pregnancies. Further research into injectable contraceptive failures on ART is warranted.
authors.affiliation: Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa. sschwartz@wrhi.ac.za
authors.forename: Sheree R
authors.initials: SR
authors.lastname: Schwartz
authors.forename: Helen
authors.initials: H
authors.lastname: Rees
authors.forename: Shruti
authors.initials: S
authors.lastname: Mehta
authors.forename: Willem Daniel Francois
authors.initials: WD
authors.lastname: Venter
authors.forename: Taha E
authors.initials: TE
authors.lastname: Taha
authors.forename: Vivian
authors.initials: V
authors.lastname: Black
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active / Q000706:statistics & numerical data*; D003142:Communication; D003270:Contraceptive Agents; D003278:Contraceptives, Oral, Hormonal; D005260:Female; D005500:Follow-Up Studies; D006282:Health Personnel / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D011247:Pregnancy; D049168:Pregnancy, Unplanned / Q000502:physiology*; D015995:Prevalence; D011446:Prospective Studies; D013019:South Africa / Q000453:epidemiology; D013997:Time Factors
chemical_list: D003270:Contraceptive Agents; D003278:Contraceptives, Oral, Hormonal