title: Effect of HIV infection on pregnancy-related mortality in sub-Saharan Africa: secondary analyses of pooled community-based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA).
abstract: BACKGROUND
  Model-based estimates of the global proportions of maternal deaths that are in HIV-infected women range from 7% to 21%, and the effects of HIV on the risk of maternal death is highly uncertain. We used longitudinal data from the Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) network to estimate the excess mortality associated with HIV during pregnancy and the post-partum period in sub-Saharan Africa.
  
  
  METHODS
  The ALPHA network pooled data gathered between June, 1989 and April, 2012 in six community-based studies in eastern and southern Africa with HIV serological surveillance and verbal-autopsy reporting. Deaths occurring during pregnancy and up to 42 days post partum were defined as pregnancy related. Pregnant or post-partum person-years were calculated for HIV-infected and HIV-uninfected women, and HIV-infected to HIV-uninfected mortality rate ratios and HIV-attributable rates were compared between pregnant or post-partum women and women who were not pregnant or post partum.
  
  
  RESULTS
  138,074 women aged 15-49 years contributed 636,213 person-years of observation. 49,568 women had 86,963 pregnancies. 6760 of these women died, 235 of them during pregnancy or the post-partum period. Mean prevalence of HIV infection across all person-years in the pooled data was 17.2% (95% CI 17.0-17.3), but 60 of 118 (50.8%) of the women of known HIV status who died during pregnancy or post partum were HIV infected. The mortality rate ratio of HIV-infected to HIV-uninfected women was 20.5 (18.9-22.4) in women who were not pregnant or post partum and 8.2 (5.7-11.8) in pregnant or post-partum women. Excess mortality attributable to HIV was 51.8 (47.8-53.8) per 1000 person-years in women who were not pregnant or post partum and 11.8 (8.4-15.3) per 1000 person-years in pregnant or post-partum women.
  
  
  CONCLUSIONS
  HIV-infected pregnant or post-partum women had around eight times higher mortality than did their HIV-uninfected counterparts. On the basis of this estimate, we predict that roughly 24% of deaths in pregnant or post-partum women are attributable to HIV in sub-Saharan Africa, suggesting that safe motherhood programmes should pay special attention to the needs of HIV-infected pregnant or post-partum women.
  
  
  BACKGROUND
  Wellcome Trust, Health Metrics Network (WHO).
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK. basia.zaba@lshtm.ac.uk
authors.forename: Basia
authors.initials: B
authors.lastname: Zaba
authors.forename: Clara
authors.initials: C
authors.lastname: Calvert
authors.forename: Milly
authors.initials: M
authors.lastname: Marston
authors.forename: Raphael
authors.initials: R
authors.lastname: Isingo
authors.forename: Jessica
authors.initials: J
authors.lastname: Nakiyingi-Miiro
authors.forename: Tom
authors.initials: T
authors.lastname: Lutalo
authors.forename: Amelia
authors.initials: A
authors.lastname: Crampin
authors.forename: Laura
authors.initials: L
authors.lastname: Robertson
authors.forename: Kobus
authors.initials: K
authors.lastname: Herbst
authors.forename: Marie-Louise
authors.initials: ML
authors.lastname: Newell
authors.forename: Jim
authors.initials: J
authors.lastname: Todd
authors.forename: Peter
authors.initials: P
authors.lastname: Byass
authors.forename: Ties
authors.initials: T
authors.lastname: Boerma
authors.forename: Carine
authors.initials: C
authors.lastname: Ronsmans
mesh_terms: D000293:Adolescent; D000328:Adult; D017954:Africa South of the Sahara; D005260:Female; D015658:HIV Infections / Q000401:mortality*; D006297:Health Services Accessibility; D006801:Humans; D008875:Middle Aged; D011159:Population Surveillance; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality*; D011251:Pregnancy Complications, Infectious / Q000401:mortality; D055815:Young Adult