1. Reproductive Health Needs of Men and Women Enrolled in HIV Care and Treatment Services Elaine Abrams August 12, 2008 Track 1.0 Meeting

2. Introduction Primary focus of PMTCT has been in the ANC and MCH With expansion of HIV care and treatment services we can expect to see women in antiretroviral (ART) clinics becoming pregnant – Clinicians report increasing numbers of women on ART ‘falling’ pregnant ART use may be associated with a higher incidence of pregnancy – Improved health status – Improved fertility – Increased desire to have children HIV Care and Treatment Services provide opportunities to: – Optimize reproductive decision making – Maximize PMTCT strategies – Support Family Planning

3. Incidence and Determinants of Pregnancy in the MTCT-Plus Initiative MTCT-Plus Initiative, a multisite comprehensive family- focused HIV care and treatment program at 11 sites in 7 countries in sub-Saharan Africa (Cameroon, Cote d’Ivoire, Kenya, Rwanda, South Africa, Uganda, and Zambia) – Pregnant or postpartum HIV-infected women receiving PMTCT services were enrolled into long-term HIV care and treatment regardless of their degree of disease progression. – All HIV-infected women received a package of HIV primary health care services (regular clinical examinations, 6-monthly CD4 cell count testing, prevention and management of opportunistic infections, psychosocial support and counseling) – Eligible women initiated highly active antiretroviral therapy following national and WHO guidelines – Barrier and non-barrier contraceptive methods were provided on-site or by referral based on local availability

4. Pregnancy Incidence in MTCT-Plus: Study Sample 4339 women enrolled from 11 sites – Median age, 27 years – Median parity, 2 ; 8% nulliparous – Median CD4 count 366 (IQR, 207-562) – 84% of women WHO stages 1 & 2 Median duration of follow-up – 476 days pre-ART – 839 days on-ART

5. Pregnancy Incidence in MTCT-Plus: Findings 590 incident pregnancies observed in total Pregnancy rate during overall observation period, 6.89 per 100 woman-years (95% CI: 6.36-7.47) – Among women pre-ART: 5.99 per 100 person-years (95% CI: 5.40-6.65) – Among women on-ART: 8.85 per 100 woman-years (95% CI: 7.79-10.05) Significant predictors of pregnancy included ART use, younger age, lower educational level, nulliparity, lack of non-barrier contraceptive use and being married/cohabiting In multivariate analysis the association between ART use and higher rate of pregnancy persisted after adjusting for demographic & clinical characteristics (HR 1.55; 95% CI: 1.22-1.96)

6. By end of 4 years of follow-up, approximately 65% of women using ART remained pregnancy-free, compared to 75% of women not on ART

7. Comments ~ 1.5 million women have initiated ART, predominantly women of reproductive age We can anticipate increasingly numbers of women becoming pregnant while engaged in care and after initiating ART during follow-up in HIV care and treatment programs Therefore there is an urgent need to – Explore reproductive decision making of men and women in HIV care and treatment programs Address provider notions about pregnancy for HIV infected women – Support the availability of family planning for those who choose to postpone/avoid pregnancy – Maximize PMTCT and safe motherhood for those who choose to become pregnant Assure appropriate management of HIV and use of ART during pregnancy

8. THANK YOU!