Page 366 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 5 of 12 Original Research

Maternal demographics Antiretroviral therapy during pregnancy

Table 1 provides a summary of maternal characteristics, Table 3 describes the in-utero antiretroviral exposures
stratified by HIV status. Of the 27 maternal deaths reported during the course of pregnancy. 3932 infants were exposed to
during the study period, 12 (44.4%) died prior to childbirth. ART during pregnancy (96.8% of HIV-exposed infants). Twin
Only 2 of the remaining 15 (13.3%) maternal deaths were births and births exposed to more than one ART regimen
captured by the surveillance team during the reporting year during pregnancy were excluded from the risk analysis.
due to restricted access to these medical records at the time of Uncertain timing of exposures due to the uncertainty of the
data collection. temporal ordering of LMP and ART initiation resulted in
almost a third (30.4%) of all singleton births being excluded
Most of the 10 417 women (10 293, 98.8%) had a known from analysis (1105 of 3632). Of the remaining births, 380
HIV status, of whom 4013 (38.5%) were HIV-positive. The (10.4%) were exposed from conception, and 653 (18.0%)
HIV-positive women had 4063 babies (live or stillborn). HIV- initiated treatment some time during the first trimester. In 56
infected women tended to be older than HIV-uninfected cases, ART exposure was classified as having occurred prior
women; teenage pregnancies in the HIV-uninfected group to pregnancy based only on self-reported timing in the
were 5 times more common than the HIV-infected cohort absence of a reported LMP.
(9.9% vs. 1.8%). Self-reported use of alcohol, tobacco and
illicit substances was higher among HIV-infected women. Congenital malformations at birth among
HIV-exposed birth outcomes
Only 195 women (1.9%) did not seek any antenatal care
before delivery. More than two-thirds (70.5%) of the cohort HIV infection in the mothers was reported in 11 of the 37
had four or more antenatal visits. However, almost half (29.7%) included CM cases (Table 2), all of whom received
ART at some time during pregnancy as described in Table 4.
(43.1%) first sought care after 20 weeks of gestation. The
prevalence of previous ABOs was reported for multigravidae Five of these infants were exposed to ART continuously from
(n = 6316) with only six women (0.1%) reporting previously conception throughout T1. One of these had a regimen
giving birth to infants with CMs. change to TDF/FTC/EFV during the second trimester of
pregnancy; two were initiated on ART at some time during
HIV prevalence increased with age, reaching 58.3% the first trimester, and four were initiated during the second
(640/1106) in women over 35 years of age. The prevalence in trimester.
multigravidae (49.2%) was more than twice that in
primigravid women (21.9%). Women who reported being In addition to the 2 neural tube defects reported among
currently employed had a higher prevalence of HIV than infants of the women on ART, a case of anencephaly was
unemployed women. Both TB and syphilis were more reported in an HIV-unexposed infant.
commonly reported in HIV-infected women.
Risk analyses
Birth outcomes The numbers in Table 3 may not directly match with those in
Among the birth outcomes reflected in Table 2, 10 197 were Tables 5 and 6 because cases with missing values for the
live births, 275 (2.6%) pregnancy losses, 85 (0.8%) NND, 852 outcomes concerned were excluded from the denominators
(8.1%) SGA and 56 (0.5%) new-borns with CMs detected in Tables 5 and 6.
at birth (Supplementary Table 1). Thirty-seven of the CMs
were eligible for inclusion in the teratogenicity analysis There was no significant difference in risk of CM in births
(Analysis A), of which 11 (29.7%) occurred in women on ART exposed to ART during the first trimester compared to
during pregnancy (described in Table 4). The other 19 CMs HIV-unexposed births and HIV-exposed births only
were excluded from the analysis based on Holmes’s criteria exposed to ART beyond T1 (2.11 [95% CI 0.65–6.92;
noted earlier. Extra two CMs were excluded from the risk p = 0.214]; Table 5).
analysis as they occurred among women whose ART
exposure time was uncertain or who switched ART regimens The first-trimester exposure to the EFV-based treatment (0.87
during critical or uncertain times. [95% CI 0.12–6.40]) was not associated with an increased risk
compared to births not exposed to ART in the first trimester.
Of the 3632 ART-exposed singleton births, the vast majority However, there was a higher risk of CMs in births with pre-
of births (3391, 93.4%) reported being on the recommended pregnancy initiation of NVP-based ART (9.28 [95% CI 2.27–
first-line adult ART regimen, TDF-FTC-EFV. There were only 37.94; p = 0.002]) compared to births not exposed to ART in
96 singleton births (2.6%) exposed to NVP-based regimens the first trimester. Similar findings were obtained when a
during pregnancy, at least 58 (60.4%) of whom were already sensitivity analysis was conducted including cases with first-
on treatment before pregnancy. In total, there were 3465 trimester ART initiation.
(95.4%) births exposed to an EFV-based ART regimen, of
which 306 (8.8%) were initiated before the pregnancy and an After adjusting for age category, parity and education,
additional 641 (18.5%) were initiated during the first trimester. ART and EFV-based ART initiation regardless of the timing

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