Incidence and Predictors of Pregnancy among a Cohort of HIV-Positive Women Initiating Antiretroviral Therapy in Mbarara, Uganda

Objective: Many people living with HIV in sub-Saharan Africa desire biological children. Implementation of HIV preventionstrategies that support the reproductive goals of people living with HIV while minimizing HIV transmission risk to sexualpartners and future children requires a comprehensive understanding of pregnancy in this population. We analyzedprospective cohort data to determine pregnancy incidence and predictors among HIV-positive women initiatingantiretroviral therapy (ART) in a setting with high HIV prevalence and fertility.Methods:Participants were enrolled in the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort of HIV-positiveindividuals initiating ART in Mbarara. Bloodwork (including CD4 cells/mm3, HIV viral load) and questionnaires (includingsocio-demographics, health status, sexual behavior, partner dynamics, HIV history, and self-reported pregnancy) werecompleted at baseline and quarterly. Our analysis includes 351 HIV-positive women (18–49 years) who enrolled between2005–2011. We measured pregnancy incidence by proximal and distal time relative to ART initiation and used multivariableCox proportional hazards regression analysis (with repeated events) to identify baseline and time-dependent predictors ofpregnancy post-ART initiation.Results:At baseline (pre-ART initiation), median age was 33 years [IQR: 27–37] and median prior livebirths was four [IQR: 2–6]. 38% were married with 61% reporting HIV-positive spouses. 73% of women had disclosed HIV status to a primary sexualpartner. Median baseline CD4 was 137 cells/mm3[IQR: 81–207]. At enrolment, 9.1% (31/342) reported current pregnancy.After ART initiation, 84 women experienced 105 pregnancies over 3.8 median years of follow-up, yielding a pregnancyincidence of 9.40 per 100 WYs. Three years post-ART initiation, cumulative probability of at least one pregnancy was 28%and independently associated with younger age (Adjusted Hazard Ratio (AHR): 0.89/year increase; 95%CI: 0.86–0.92) and HIVserostatus disclosure to primary sexual partner (AHR: 2.45; 95%CI: 1.29–4.63).Conclusions:Nearly one-third of women became pregnant within three years of initiating ART, highlighting the need forintegrated services to prevent unintended pregnancies and reduce periconception-related risks for HIV-infected womenchoosing to conceive. Association with younger age and disclosure suggests a role for early and couples-based safer conception counselling