Swelling number of pregnant HIV positive women baffles experts

A sharp rise in pregnancies among women on anti-retroviral treatment in Kenya and several other African countries has medical researchers baffled. The women have been found to be twice as likely to become pregnant compared to those not on medication, says a study published recently in the Journal of Medicine.

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Researchers are worried that the increased pregnancies could lead to a rise in HIV positive babies. Of an estimated 1.5 million women who get pregnant in Kenya annually, about 100,000 are HIV positive. Studies show that about 45,000 of the babies they give birth to will be infected.

In the latest survey, researchers studied the women over a four-year period and found that nearly a third of those on anti-retrovirals had experienced a pregnancy. “The chance of pregnancy increased over time in women on drugs to almost 80 per cent greater than those not on medication,” the study says.

The link between ARVs and the high rate of pregnancy is not clear but experts think women on medication may feel more motivated to have children as their health and quality of life improve. “However, we did not examine how pregnancy desires and sexual activity of women changed while on ART, and cannot discern why the medicines are linked to increased pregnancy,” say the researchers from the universities of Columbia in the US and Cape Town in South Africa.

The new development presents a new challenge to HIV programmes to address the higher fertility and the possibility of increased cases of mother-to-child transmission. “HIV care and treatment services must strengthen medical as well as psycho-social care to address fertility desires and plans for both women and men with HIV infection,” the study says.

For women who do not wish to become pregnant, it is suggested that effective methods of contraception as well as safe abortion services be made available. But for women who desire a child, they should be supported in planning a pregnancy, the choice of anti-retrovirals and when and how to start on mother-to-child transmission treatment.

Ideally, pregnant women should visit an ante-natal clinic at 14 weeks so that in the event they are HIV positive, they are put on treatment to prevent transmission to the baby. Dr Nicholas Muraguri, head of the National Aids and STDs Control Programme, says many HIV positive women in Kenya are not utilising a family planning programme that is in place.

Stable relationship

“The government has a family planning programme to reduce pregnancies among HIV positive women but 50 per cent of the women who should be using it are not,” says Dr Muraguri. The rise in pregnancy and sexual activity has been found to be highest among those in stable relationships.

The researchers sampled women in Kenya, Rwanda, Uganda, Cote d’Ivoire, Zambia, Malawi and South Africa. In Kenya, the study was conducted at the Nyanza Provincial General Hospital in Kisumu and Mosoriot Rural Health Centre near Eldoret.

According to the authors, related studies from Africa suggest that “HIV might modify but does not eliminate a broader desire to have children and that ART use may be associated with increased fertility desire among HIV-infected women possibly through increased hope and planning for the future”.

This means the level of confidence among HIV positive women is being inspired by the prolonged life that ART services bring, although scientists say there is still a high risk of the unborn child being infected. “This study suggests that starting ART is associated with higher pregnancy rates in sub-Saharan Africa, nearly doubling the chances of a woman becoming pregnant. “However, ART reduces but does not remove the chance of the mother passing HIV to her child at birth,” says the study.

Condom use

The 4,531 women enrolled for the study at 11 sites in 2003 were issued with a package of HIV primary care services which included clinical reviews and CD4 cell counts after every six months, but were not counselled on pregnancy and contraceptive use.

By the time the research was ending, six to nine of a group of 100 HIV positive women had conceived in all the countries under the study, except in South Africa and Rwanda, where the rates were lower.

It, however, shows that women in the 25 and 35-year age bracket are more likely to yearn for a baby in all the countries studied, although the level of education, being married, having a male partner enrolled into an HIV/Aids programme and use of contraceptives influence the likelihood of an HIV positive woman getting pregnant.

For instance, the study observed that condom use may not necessarily prevent pregnancy compared to other conventional methods of contraception. “The high incidence of pregnancy coupled with the low prevalence of contraceptive use underscore the importance of addressing fertility-related issues within HIV care and treatment programmes in sub-Saharan Africa,” says the study.

The study recommends the introduction of pregnancy programmes for HIV positive women and suggests that safe abortion services should be made available for women who may conceive accidentally through insecure contraception. “These findings highlight the importance of pregnancy planning and management as a critical component of HIV care and treatment services,” says the study.