title: Hormonal Contraception, Pregnancy, Breastfeeding, and Risk of HIV Disease Progression Among Zambian Women.
abstract: BACKGROUND
  Some studies suggest that hormonal contraception, pregnancy, and/or breastfeeding may influence rates of HIV disease progression.
  
  
  METHODS
  From 1994 to 2012, HIV discordant couples recruited at couples' voluntary HIV counseling and testing centers in Lusaka were followed 3-monthly. Multivariate survival analyses explored associations between time-varying contraception, pregnancy, and breastfeeding and 2 outcomes among HIV-positive women: (1) time to death and (2) time to antiretroviral treatment (ART) initiation.
  
  
  RESULTS
  Among 1656 female seropositive, male seronegative couples followed for 3359 person-years (PY), 224 women died [6.7/100 PY; 95% confidence interval (CI): 5.8 to 7.6]. After 2003, 290 women initiated ART (14.5/100 PY; 95% CI: 12.9 to 16.2). In a multivariate model of time to death, hormonal implant [adjusted hazard ratio (aHR) = 0.30; 95% CI: 0.10 to 0.98] and injectable (aHR = 0.59; 95% CI: 0.36 to 0.97) were significantly protective relative to nonhormonal method use, whereas oral contraceptive pill (OCP) use was not (aHR = 1.08; 95% CI: 0.74 to 1.57) controlling for baseline HIV disease stage, time-varying pregnancy, time-varying breastfeeding, and year of enrollment. In a multivariate model of time-to-ART initiation, implant was significantly protective (aHR = 0.54; 95% CI: 0.31 to 0.95), whereas OCP (aHR = 0.70; 95% CI: 0.44 to 1.10) and injectable (aHR = 0.85; 95% CI: 0.55 to 1.32) were not relative to nonhormonal method use controlling for variables above, woman's age, and literacy. Pregnancy was not significantly associated with death (aHR = 1.07; 95% CI: 0.68 to 1.66) or ART initiation (aHR = 1.24; 95% CI: 0.83 to 1.86), whereas breastfeeding was protective for death (aHR = 0.34; 95% CI: 0.19 to 0.62) and ART initiation (aHR = 0.49; 95% CI: 0.29 to 0.85).
  
  
  CONCLUSIONS
  Hormonal implants and injectables significantly predicted lower mortality; implants were protective for ART initiation. OCPs and pregnancy were not associated with death or ART initiation, whereas breastfeeding was protective for both. Findings from this 18-year cohort study suggest that (1) HIV-positive women desiring pregnancy can be counseled to do so and breastfeed and (2) all effective contraceptive methods, including injectables and implants, should be promoted to prevent unintended pregnancy.
authors.affiliation: *Department of Pathology and Laboratory Medicine, Rwanda, Zambia HIV Research Group, School of Medicine, Atlanta, GA; †Hubert, Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA; ‡Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA; §Department of Gynecology and Obstetrics, Emory University, School of Medicine, Atlanta, GA; ‖Departments of Gynecology and Obstetrics and Internal Medicine, School of Medicine, University of Zambia, Lusaka, Zambia; ¶Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, AL; and #Ministry of Community Development, Mother and Child Health, Lusaka, Zambia.
authors.forename: Kristin M
authors.initials: KM
authors.lastname: Wall
authors.forename: William
authors.initials: W
authors.lastname: Kilembe
authors.forename: Lisa
authors.initials: L
authors.lastname: Haddad
authors.forename: Bellington
authors.initials: B
authors.lastname: Vwalika
authors.forename: Shabir
authors.initials: S
authors.lastname: Lakhi
authors.forename: Naw Htee
authors.initials: NH
authors.lastname: Khu
authors.forename: Ilene
authors.initials: I
authors.lastname: Brill
authors.forename: Elwyn
authors.initials: E
authors.lastname: Chomba
authors.forename: Joseph
authors.initials: J
authors.lastname: Mulenga
authors.forename: Amanda
authors.initials: A
authors.lastname: Tichacek
authors.forename: Susan
authors.initials: S
authors.lastname: Allen
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D001942:Breast Feeding; D015331:Cohort Studies; D003271:Contraceptive Agents, Female / Q000494:pharmacology*; D018450:Disease Progression; D004343:Drug Implants; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology / Q000473:pathology*; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D011247:Pregnancy; D016016:Proportional Hazards Models; D012307:Risk Factors; D015024:Zambia / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents; D003271:Contraceptive Agents, Female; D004343:Drug Implants