1. Pregnancy and living with HIV
Coceka Nandipha Mnyani
South Africa

2. Conflict of Interest
No conflicts of interest to declare.

3. Successes in PMTCT
: 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

4. The Soweto success story

5. ….but, it is more than just about PMTCT

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

7. 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

8. 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’

9. 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

10. 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

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

12. 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)

13. Why maternal deaths still in women living with HIV?
Maternal deaths at CHBAH, SA – (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

14. 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

15. 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)

16. 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

17. 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)
> peripartum women, 51% CD4 <350, 81% on ART
Pre-existing anaemia

18. 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