Pregnancy and living with HIV Coceka Nandipha Mnyani South Africa

Conflict of Interest No conflicts of interest to declare.

Successes in PMTCT 2009-2015: new paediatric HIV infections reduced by 60% in the 21 priority countries (SSA) >80% decrease – Uganda (86%), South Africa (84%), Burundi (84%) ‘…one of the great public health achievements of recent times’ UNAIDS 2016

The Soweto success story

….but, it is more than just about PMTCT

Maternal health pregnancy and HIV disease progression mortality Obstetric complications …….addressing the known and unknown

Study done in SA, 2004 – 2011 7 534 ART-naïve women; median follow-up 14 months 21 deaths (2.3%) in 918 women who became pregnant vs. 614 deaths (9.3%) in 6 616 women who did not

At time of pregnancy, median time on ART was 14 months (IQR: 7; 26); majority virally suppressed, CD4 >200 Conclusion: incident pregnancy not associated with increased risk of disease progression or death in women on ART associated with a decreased risk of LTFU …….‘healthy pregnant women effect’

To explore effects of incident pregnancy (after ART initiation) on virologic, immunologic, and clinical response to ART 3 prospective studies of HIV discordant couples From 7 African countries; 2004 to 2012

110/1041 women pregnant after ART initiation Pregnancy not associated with time to: viral suppression virologic failure WHO clinical stage III or IV disease Associated with mean decrease in CD4 count of 47 – physiological haemodilution

…third leading cause of death among women aged 15-29 globally

Maternal mortality in the era of ART Survival benefit of ART – even without advanced immune suppression (Marazzi MC et al. AIDS 2011; 25:1611–1618) Suggestion of a decline in maternal mortality with Option B+ (CD4 >350) (Auld AF et al. JAIDS 2016; 73:e11–e22) 50% decline in odds of (maternal) death from TB with expansion of ART programme (Black V et al. PLoS ONE 2016; 11)

Why maternal deaths still in women living with HIV? Maternal deaths at CHBAH, SA – 1997-2015 (n=692) 335 HIV+ – 83.8% (281) diagnosed during pregnancy Median CD4 count 136 Non-pregnancy related infections the leading cause of maternal deaths, but proportion decreasing

Why maternal deaths still in women living with HIV? 521/692 still pregnant on admission 524/692 of deaths occurred postpartum In most cases, conditions that led to the deaths occurred antenatally and intrapartum Unknown HIV status likely to: not have accessed antenatal care; die within the first 24 hours of admission; at an early gestational age

Obstetric complications and maternal deaths Puerperal sepsis, complications of hypertensive disorders, obstetric haemorrhage ?increased risk in women living with HIV …only consensus with puerperal sepsis – highest risk consistently shown to be with non-elective CS …even with widespread availability of ART (Kourtis AP et al. AIDS 2014; 28:2609–2618; Livingston EG et al. JAIDS 2016;73:74–82)

Obstetric complications Hypertensive disorders in pregnancy – pathophysiology complex Thought to have an immunologic basis Modifying effect of ART …vs. inflammatory changes associated with HIV Data inconsistent

Obstetric complications Obstetric haemorrhage – data inconsistent Definition of PPH used in studies not the same But, women with HIV more likely to receive blood and blood products (Bloch EM et al. Transfusion 2015; 55:1675–1684) >15 000 peripartum women, 51% CD4 <350, 81% on ART Pre-existing anaemia

Conclusion …it is more than just about PMTCT Need to shift focus to include maternal health; maternal mortality still a concern Reassuring data on pregnancy, HIV disease progression, and response to ART Accessing antenatal care remains critical