title: High Proportion of Deaths Attributable to HIV Among Postpartum Women in Botswana Despite Widespread Uptake of Antiretroviral Therapy.
abstract: Mortality in the postpartum period may be impacted by antiretroviral therapy (ART) received in pregnancy, and whether ART is continued in the postpartum period. HIV-infected and HIV-uninfected mothers were enrolled within 48 h of delivery at five public hospital maternity wards throughout Botswana and followed for 24 months. Maternal deaths were reported by one of the approved contacts given by the mother at enrollment. Detailed information on the cause of death was not available. Risk factors for 24-month mortality were assessed using Cox proportional hazard models. From February 2012 to March 2013, 3000 mothers (1499 HIV infected and 1501 HIV uninfected) were enrolled, and 2985 (99.5%) were followed to 24 months or death, or until the death of their child. There were 26 total maternal deaths through 24 months postpartum [439 per 100,000 person-years (p-y)], 22 among HIV-infected women (758 per 100,000 p-y) and 4 among HIV-uninfected women (132 per 100,000 p-y). Maternal HIV-infection (aHR 5.0, 95% CI 1.6-15.2) and infant birth injury (aHR 3.8, 95% CI 1.3-11.4) were independent risk factors for maternal death. Universal ART in pregnancy became the standard-of-care after June 2012, and 978 (65%) women received ART in pregnancy; by 24 months postpartum or end of follow-up, 1148 (79%) had started ART overall. There was no significant difference in 24-month mortality among HIV-infected women who took ART in pregnancy and continued throughout the follow-up period compared with HIV-infected women who took ART or zidovudine in pregnancy and stopped postpartum (aHR 0.6, 95% CI 0.2-1.7). Despite high uptake of ART in pregnancy and postpartum, women with HIV infection in Botswana are five times more likely to die than HIV-uninfected women in the 24 months postpartum.
authors.affiliation: 1 Division of Infectious Diseases, Beth Israel Deaconess Medical Center , Boston, Massachusetts.|2 Immunology and Infectious Diseases, TH Chan Harvard School of Public Health , Boston, Massachusetts.|3 Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana .
authors.forename: Rebecca Marie
authors.initials: RM
authors.lastname: Zash
authors.affiliation: 4 Department of Pathology, Faculty of Medicine, University of Botswana , Gaborone, Botswana .
authors.forename: Sajini
authors.initials: S
authors.lastname: Souda
authors.affiliation: 5 Goodtables Data Consulting , Norman, Oklahoma.
authors.forename: Jean
authors.initials: J
authors.lastname: Leidner
authors.affiliation: 3 Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana .
authors.forename: Kelebogile
authors.initials: K
authors.lastname: Binda
authors.affiliation: 6 Care Quality Commission , London, United Kingdom .
authors.forename: Chazha
authors.initials: C
authors.lastname: Hick
authors.affiliation: 2 Immunology and Infectious Diseases, TH Chan Harvard School of Public Health , Boston, Massachusetts.|3 Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana .|7 Department of Medicine and Pediatrics, Massachusetts General Hospital , Boston, Massachusetts.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Powis
authors.affiliation: 3 Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana .
authors.forename: Joseph
authors.initials: J
authors.lastname: Makhema
authors.affiliation: 3 Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana .
authors.forename: Mompati
authors.initials: M
authors.lastname: Mmalane
authors.affiliation: 2 Immunology and Infectious Diseases, TH Chan Harvard School of Public Health , Boston, Massachusetts.|3 Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana .
authors.forename: Max
authors.initials: M
authors.lastname: Essex
authors.affiliation: 2 Immunology and Infectious Diseases, TH Chan Harvard School of Public Health , Boston, Massachusetts.|3 Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana .|8 Division of Infectious Diseases, Brigham and Women's Hospital , Boston, Massachusetts.
authors.forename: Shahin
authors.initials: S
authors.lastname: Lockman
authors.affiliation: 1 Division of Infectious Diseases, Beth Israel Deaconess Medical Center , Boston, Massachusetts.|2 Immunology and Infectious Diseases, TH Chan Harvard School of Public Health , Boston, Massachusetts.|3 Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana .
authors.forename: Roger L
authors.initials: RL
authors.lastname: Shapiro
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D001902:Botswana / Q000453:epidemiology; D016022:Case-Control Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000208:ethnology / Q000401:mortality*; D006801:Humans; D007223:Infant; D018445:Infectious Disease Transmission, Vertical; D063130:Maternal Death / Q000706:statistics & numerical data*; D055118:Medication Adherence; D009035:Mothers / Q000523:psychology*; D049590:Postpartum Period; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy* / Q000401:mortality*; D011446:Prospective Studies; D016019:Survival Analysis; D015215:Zidovudine / Q000627:therapeutic use
chemical_list: D044966:Anti-Retroviral Agents; D015215:Zidovudine
keywords: HIV; antiretroviral; prenatal