title: Effect of Pregnancy on Response to Antiretroviral Therapy in HIV-Infected African Women.
abstract: 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 in 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 Herpes simplex virus/HIV Transmission Study, Couples Observational Study, and Partners Preexposure Prophylaxis Study) from 7 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 per milliliter ≥6 months after ART initiation and viral suppression was defined as VL ≤400 copies per milliliter. Multivariable Cox proportional hazards models were used to assess the association between pregnancy and time to viral suppression, virologic failure, World Health Organization 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 before ART initiation was 276 cells per cubic millimeter (interquartile range, 209-375); median pre-ART VL was 17,511 copies per milliliter (interquartile range, 2480-69,286). One hundred ten women became pregnant after ART initiation. Pregnancy was not associated with time to viral suppression (adjusted hazard ratio [aHR], 1.20, 95% confidence interval [CI]: 0.82 to 1.77), time to virologic failure (aHR, 0.67, 95% CI: 0.37 to 1.22), time to World Health Organization clinical stage III or IV (aHR, 0.79, 95% CI: 0.19 to 3.30), or time to death (aHR, 2.04, 95% CI: 0.25 to 16.8). Incident pregnancy was associated with an adjusted mean decrease in CD4 T-cell count of 47.3 cells per cubic millimeter (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.
authors: *Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA; Departments of †Epidemiology; ‡Global Health, University of Washington, Seattle, WA; §Sexual, Reproductive, Adolescent and Child Health Research Program, Kenya Medical Research Institute, Nairobi, Kenya; ‖Contraceptive Technology Innovation Department, FHI 360, Durham, NC; ¶Vaccine and Infectious Disease Division Fred Hutchinson Cancer Research Center, Seattle, WA; Departments of #Medicine; and **Pediatrics, University of Washington, Seattle, WA.
authors: Athena P
authors: AP
authors: Kourtis
authors: Jeffrey
authors: J
authors: Wiener
authors: Caroline C
authors: CC
authors: King
authors: Renee
authors: R
authors: Heffron
authors: Nelly R
authors: NR
authors: Mugo
authors: Kavita
authors: K
authors: Nanda
authors: Maria
authors: M
authors: Pyra
authors: Deborah
authors: D
authors: Donnell
authors: Connie
authors: C
authors: Celum
authors: Jairam R
authors: JR
authors: Lingappa
authors: Jared M
authors: JM
authors: Baeten
mesh_terms: D000328:Adult; D000349:Africa; D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D018791:CD4 Lymphocyte Count; D005260:Female; D006678:HIV / Q000302:isolation & purification; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000473:pathology / Q000821:virology; D006801:Humans; D008297:Male; D010949:Plasma / Q000821:virology; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy* / Q000276:immunology / Q000473:pathology / Q000821:virology; D011446:Prospective Studies; D016896:Treatment Outcome; D019562:Viral Load
chemical_list: D044966:Anti-Retroviral Agents