title: Incident pregnancy and time to death or AIDS among HIV-positive women receiving antiretroviral therapy.
abstract: BACKGROUND
  Little is known about the impact of pregnancy on response to highly active antiretroviral therapy (HAART) in sub-Saharan Africa. We examined the effect of incident pregnancy after HAART initiation on clinical response to HAART.
  
  
  METHODS
  We evaluated a prospective clinical cohort of adult women initiating HAART in Johannesburg, South Africa between 1 April 2004 and 31 March 2011, and followed up until an event, transfer, drop-out, or administrative end of follow-up on 30 September 2011. Women over age 45 and women who were pregnant at HAART initiation were excluded from the study. Main exposure was having experienced pregnancy after HAART initiation; main outcome was death and (separately) death or new AIDS event. We calculated adjusted hazard ratios (HRs) and 95% confidence limits (CL) using marginal structural Cox proportional hazards models.
  
  
  RESULTS
  The study included 7,534 women, and 20,813 person-years of follow-up; 918 women had at least one recognized pregnancy during follow-up. For death alone, the weighted (adjusted) HR was 0.84 (95% CL 0.44, 1.60). Sensitivity analyses confirmed main results, and results were similar for analysis of death or new AIDS event. Incident pregnancy was associated with a substantially reduced hazard of drop-out (HR = 0.62, 95% CL 0.51, 0.75).
  
  
  CONCLUSIONS
  Recognized incident pregnancy after HAART initiation was not associated with increases in hazard of clinical events, but was associated with a decreased hazard of drop-out. High rates of pregnancy after initiation of HAART may point to a need to better integrate family planning services into clinical care for HIV-infected women.
authors.affiliation: Department of Obstetrics and Gynecology and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America. Erica.Pierce@ucdenver.edu
authors.forename: Daniel
authors.initials: D
authors.lastname: Westreich
authors.forename: Mhairi
authors.initials: M
authors.lastname: Maskew
authors.forename: Denise
authors.initials: D
authors.lastname: Evans
authors.forename: Cindy
authors.initials: C
authors.lastname: Firnhaber
authors.forename: Pappie
authors.initials: P
authors.lastname: Majuba
authors.forename: Ian
authors.initials: I
authors.lastname: Sanne
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy* / Q000401:mortality*; D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D005260:Female; D005500:Follow-Up Studies; D006679:HIV Seropositivity / Q000188:drug therapy* / Q000401:mortality*; D006801:Humans; D015994:Incidence; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy* / Q000401:mortality*; D012189:Retrospective Studies