Impact of antiretroviral therapy on incidence of pregnancy among HIV-infected women in Sub-Saharan Africa: a cohort study.
Impact of antiretroviral therapy on incidence of pregnancy among HIV-infected women in Sub-Saharan Africa: a cohort study.
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DOI：
10.1371/journal.pmed.1000229
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发表时间：
2010-02-09
期刊：
影响因子：
15.8
通讯作者：
Abrams EJ
中科院分区：
文献类型：
--
作者：
Myer L;Carter RJ;Katyal M;Toro P;El-Sadr WM;Abrams EJ
Landon Myer及其同事在撒哈拉以南非洲进行的一项多国队列研究显示，接受抗逆转录病毒治疗（ART）的艾滋病毒感染妇女的怀孕率更高。随着抗逆转录病毒治疗服务在撒哈拉以南非洲的迅速扩大，人们日益认识到感染艾滋病毒的妇女生育和生育的重要性。然而，很少有数据表明开始抗逆转录病毒治疗是否会影响怀孕率。我们分析了母婴传播计划（MTCT-Plus）的数据，该计划是一项针对妇女、儿童和家庭的多国艾滋病毒护理和治疗计划。在7个非洲国家的11个项目中，不论艾滋病毒处于何种阶段，妇女都参加了护理，并定期随访；抗逆转录病毒治疗是根据基于免疫学和/或临床标准的国家指南启动的。使用标准化表格收集社会人口学和临床数据，包括意外怀孕。在该分析纳入的4,531名妇女中，共观察到589例意外妊娠（妊娠发生率，7.8/100人年[PY]）。接受抗逆转录病毒治疗的妇女的新怀孕率（9.0/100 PY）明显高于未接受抗逆转录病毒治疗的妇女（6.5/100 PY）（调整后的风险比为1.74；95%可信区间为1.19-2.54）。其他与意外怀孕风险增加独立相关的因素包括年龄较小，受教育程度较低，已婚或同居，有男性伴侣参加该计划，未使用无障碍避孕措施，以及CD4细胞计数较高。在撒哈拉以南非洲，抗逆转录病毒药物的使用与感染艾滋病毒的妇女怀孕率明显较高有关。虽然这种关联背后可能的行为或生物医学机制需要进一步调查，但这些数据强调了怀孕计划和管理作为艾滋病毒护理和治疗服务中一个关键但被忽视的组成部分的重要性。人类免疫缺陷病毒（艾滋病毒）导致获得性免疫缺陷综合症（艾滋病），这是全球主要的疾病和死亡原因，请参阅文章后面的编辑摘要。全世界有3300多万人感染艾滋病毒，每天有近5500人死于艾滋病毒和艾滋病相关并发症。艾滋病毒/艾滋病在撒哈拉以南非洲尤其成问题，在那里它是导致死亡的主要原因。目前还没有治愈艾滋病毒/艾滋病的方法，但是被称为“抗逆转录病毒疗法”（ART）的药物可以延长艾滋病毒感染者的生命并减少并发症。97%的艾滋病毒/艾滋病患者生活在低收入和中等收入国家。据世界卫生组织称，这些患者中有近1000万人需要抗逆转录病毒治疗。由于抗逆转录病毒药物的高成本和低可得性往往阻碍患者获得治疗，全球卫生工作的重点是在资源有限的国家促进抗逆转录病毒药物的使用。这些努力还提高了人们对艾滋病毒传播方式（接触血液或精液、性交、共用针头或分娩时母婴传播）的认识。抗逆转录病毒疗法减少，但不能消除母亲在分娩时将艾滋病毒传染给孩子的机会。到2007年底，贫穷国家有300万艾滋病毒感染者正在接受抗逆转录病毒治疗。许多接受抗逆转录病毒治疗的人是育龄的年轻妇女。在撒哈拉以南非洲，分娩是艾滋病毒传播的一个重要途径，那里60%的艾滋病毒患者是妇女。这项研究质疑抗逆转录病毒治疗所带来的健康和预期寿命的改善是否会影响艾滋病毒感染者的怀孕率。这项研究在七个非洲国家探讨了这个问题，通过检查感染艾滋病毒的妇女在开始抗逆转录病毒治疗之前和之后的怀孕率。这组作者研究了在7个非洲国家参加“母婴传播+”（MTCT-Plus）计划的4531名感染艾滋病毒的妇女的记录。2002年开始的MTCT -Plus是一个以家庭为中心的治疗项目，为妇女及其家人提供定期检查、血液检查、咨询和抗逆转录病毒治疗（如果适当）。在每次检查中，妇女的CD4+细胞计数和世界卫生组织的指导方针被用来确定她们是否有资格开始抗逆转录病毒治疗。在4年期间，近三分之一开始抗逆转录病毒治疗的妇女怀孕：“抗逆转录病毒治疗前”组（未接受抗逆转录病毒治疗的妇女）有244例怀孕，而“未接受抗逆转录病毒治疗”组（接受抗逆转录病毒治疗的妇女）有345例怀孕。随着时间的推移，非art组的怀孕几率比art前组高出近80%，而art前组的怀孕几率相对较低且保持不变。作者指出，正如预期的那样，其他因素也增加了怀孕的机会，包括年龄较小，教育程度较低，以及使用非障碍避孕方法，如注射激素。这项研究表明，在撒哈拉以南非洲，开始抗逆转录病毒治疗与较高的怀孕率有关，使妇女怀孕的机会几乎增加了一倍。这种联系的原因尚不清楚。一种可能的解释是行为上的：接受抗逆转录病毒治疗的妇女随着健康和生活质量的改善，可能会更有动力生孩子。然而，这项研究并没有调查女性在接受抗逆转录病毒治疗时的怀孕欲望和性活动是如何改变的，也无法辨别为什么抗逆转录病毒治疗与怀孕增加有关。通过使用从患者问卷而不是实验室测试中收集的妊娠数据，该研究受到患者报告不准确的可能性的限制。了解接受抗逆转录病毒治疗的艾滋病毒感染妇女的怀孕率如何变化，有助于形成反应迅速、有效的艾滋病毒规划。在撒哈拉以南非洲接受抗逆转录病毒治疗的患者中，育龄女性艾滋病毒患者占大多数，她们将受益于将开始艾滋病毒治疗与抗逆转录病毒治疗与教育、避孕咨询和妊娠相关护理相结合的项目。请通过本摘要的在线版本http://dx.doi.org/10.1371/journal.pmed.1000229访问这些网站。可从美国国家过敏和传染病研究所获得有关艾滋病毒感染和艾滋病的信息。HIV InSite有关于艾滋病毒/艾滋病各个方面的全面信息。包括一份关于感染艾滋病毒的青少年初级保健的文章清单和其他信息来源：联合国艾滋病规划署2008年关于全球艾滋病流行病的报告；国际计划生育基金会提供关于性健康和生殖健康以及艾滋病毒的信息；哥伦比亚大学梅尔曼公共卫生学院国际艾滋病护理和治疗方案中心提供信息，协助资源有限环境下的艾滋病毒护理和治疗方案
A multicountry cohort study in sub-Saharan Africa by Landon Myer and colleagues reveals higher pregnancy rates in HIV-infected women on antiretroviral therapy (ART). With the rapid expansion of antiretroviral therapy (ART) services in sub-Saharan Africa there is growing recognition of the importance of fertility and childbearing among HIV-infected women. However there are few data on whether ART initiation influences pregnancy rates. We analyzed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multicountry HIV care and treatment program for women, children, and families. From 11 programs in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals; ART was initiated according to national guidelines on the basis of immunological and/or clinical criteria. Standardized forms were used to collect sociodemographic and clinical data, including incident pregnancies. Overall 589 incident pregnancies were observed among the 4,531 women included in this analysis (pregnancy incidence, 7.8/100 person-years [PY]). The rate of new pregnancies was significantly higher among women receiving ART (9.0/100 PY) compared to women not on ART (6.5/100 PY) (adjusted hazard ratio, 1.74; 95% confidence interval, 1.19–2.54). Other factors independently associated with increased risk of incident pregnancy included younger age, lower educational attainment, being married or cohabiting, having a male partner enrolled into the program, failure to use nonbarrier contraception, and higher CD4 cell counts. ART use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioral or biomedical mechanisms that may underlie this association require further investigation, these data highlight the importance of pregnancy planning and management as a critical but neglected component of HIV care and treatment services. Please see later in the article for the Editors' Summary Human immunodeficiency virus (HIV) causes Acquired Immunodeficiency Syndrome (AIDS), which is a major global cause of disease and death. More than 33 million people around the world are infected with HIV, with nearly 5,500 dying daily from HIV and AIDS-related complications. HIV/AIDS is especially problematic in sub-Saharan Africa, where it is the leading cause of death. There is no cure for HIV/AIDS, but medicines known as “antiretroviral therapy” (ART) can prolong life and reduce complications in patients infected with HIV. 97% of patients with HIV/AIDS live in low- and middle-income countries. According to the World Health Organization, nearly 10 million of these patients need ART. As patients' access to treatment is often hindered by the high cost and low availability of ART, global health efforts have focused on promoting ART use in resource-limited nations. Such efforts also increase awareness of how HIV is spread (contact with blood or semen, in sexual intercourse, sharing needles, or from mother to child during childbirth). ART reduces, but does not remove, the chance of a mother's passing HIV to her child during birth. By the end of 2007, 3 million HIV-infected patients in poor countries were receiving ART. Many of those treated with ART are young women of child-bearing age. Childbirth is an important means of spreading HIV in sub-Saharan Africa, where 60% of all HIV patients are women. This study questions whether the improved health and life expectancy that results from treatment with ART affects pregnancy rates of HIV-infected patients. The study explores this question in seven African countries, by examining the rates of pregnancy in HIV-infected women before and after they started ART. The authors looked at the records of 4,531 HIV-infected women enrolled in the Mother-to-Child-Transmission-Plus (MTCT-Plus) Initiative in seven African countries. MTCT -Plus, begun in 2002, is a family-centered treatment program that offers regular checkups, blood tests, counseling, and ART treatment (if appropriate) to women and their families. At each checkup, women's CD4+ cell counts and World Health Organization guidelines were used to determine their eligibility for starting ART. Over a 4-year period, nearly a third of the women starting ART experienced a pregnancy: 244 pregnancies occurred in the “pre-ART” group (women not receiving ART) compared to 345 pregnancies in the “on-ART” group (women receiving ART). The chance of pregnancy increased over time in the on-ART group to almost 80% greater than the pre-ART group, while remaining relatively low and constant in the pre-ART group. The authors noted that, as expected, other factors also increased the chances of pregnancy, including younger age, lower educational status, and use of nonbarrier contraception such as injectable hormones. 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. The reasons for this link are unclear. One possible explanation is behavioral: women receiving ART may feel more motivated to have children as their health and quality of life improve. However, the study did not examine how pregnancy desires and sexual activity of women changed while on ART, and cannot discern why ART is linked to increased pregnancy. By using pregnancy data gathered from patient questionnaires rather than laboratory tests, the study is limited by the possibility of inaccurate patient reporting. Understanding how pregnancy rates vary in HIV-infected women receiving ART helps support the formation of responsive, effective HIV programs. Female HIV patients of child-bearing age, who form the majority of patients receiving ART in sub-Saharan Africa, would benefit from programs that combine starting HIV treatment with ART with education and contraception counseling and pregnancy-related care. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000229. Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS HIV InSite has comprehensive information on all aspects of HIV/AIDS, including a list of articles and other sources of information about the primary care of adolescents with HIV A UNAIDS 2008 report is available on the global AIDS epidemic The International Planned Parenthood Foundation provides information on sexual and reproductive health and HIV The International Center for AIDS Care and Treatment Programs at the Columbia University Mailman School of Public health provides information to assist HIV care and treatment programs in resource-limited settings
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DOI：
10.1080/13625180701829952
发表时间：
2008-06-01
影响因子：
1.7
作者：
El-Ibiary, Shareen Y.;Cocohoba, Jennifer M.
通讯作者：
Cocohoba, Jennifer M.
影响因子：
3.8
作者：
Massad, LS;Springer, G;Minkofp, H
通讯作者：
Minkofp, H
影响因子：
2.9
作者：
Hubacher, David;Mavranezouli, Ifigeneia;McGinn, Erin
通讯作者：
McGinn, Erin
DOI：
10.1080/01674820701409959
发表时间：
2007-06-01
影响因子：
3.1
作者：
Dyer, Silks J.
通讯作者：
Dyer, Silks J.
DOI：
10.2307/2673717
发表时间：
2001-07-01
期刊：
FAMILY PLANNING PERSPECTIVES
影响因子：
--
作者：
Chen, JL;Phillips, KA;Miu, A
通讯作者：
Miu, A