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Does pregnancy speed HIV progression?

Whether pregnancy affects the course of HIV infection is an important question for HIV-infected women interested in using hormonal contraception. Such women need to weigh the potential--but still unproven--risk of accelerated progression to AIDS among hormonal contraceptive users (see article, page 15) against the risk of an unintended pregnancy resulting from reliance on a less effective contraceptive method.

Because pregnancy itself is thought to suppress immunity, concerns have been raised that pregnancy in HIV-infected women could hasten HIV-related deterioration of the immune system. (1) But the evidence to date suggests that pregnancy does not have such an effect, at least in the short term. (2)

Early reports of pregnancy in HIV-infected women seemed to support the hypothesis that pregnancy accelerates HIV disease progression. However, these studies involved small numbers of women and lacked control groups or the ability to adjust for other factors known to influence disease progression, such as disease stage or time of HIV exposure. (3) A systematic review of studies published from 1983 to 1996 on pregnancy's effect on HIV progression and survival found a weak association between HIV disease progression and pregnancy in HIV-infected women, but it concluded that the potential for study bias was too great to draw definitive conclusions. (4)

A study published in 2000 was able to control for many potential confounding factors, including time since seroconversion (when virus can be detected in the blood), which occurs about three months after HIV infection. This study, which followed 365 HIV-infected French women--241 of whom were pregnant--detected no increased risk of HIV progression during pregnancy. (5) Like other prospective studies with similar findings, (6) the French study involved mostly women who had not yet developed symptoms of HIV disease. Therefore, the possibility of increased risk of disease progression among pregnant women with more advanced HIV infection could not be ruled out.

Several studies from developing countries also suggest that pregnancy does not increase the risk of disease progression. In a study among HIV-infected women in Haiti, no statistically significant difference was observed in the rate of progression to AIDS or death between 44 pregnant women and 96 nonpregnant women. (7) And two studies in sub-Saharan Africa--one among 823 pregnant Kenyan women and another that included 229 pregnant women in Malawi--detected no statistically significant differences in immune status between HIV-positive and HIV-negative women during pregnancy. (8)

"Of course, more rigorous studies are needed," says Dr. Marleen Temmerman, principal investigator of the Kenya study and professor of obstetrics and gynecology at the University of Ghent in Belgium. "But most studies in Europe, the United States, and Africa did not show an impact on disease progression, so if there is any impact at all, it will be a very minimal one."

References

(1) Vimercati A, Greco P, Lopalco PL, et al. Immunological markers in HIV-infected pregnant and nonpregnant women. Eur J Obstet Gynecol Reprod Biol 2000;90(1):37-41.

(2) Watts H. Effect of pregnancy. J Acquir Immune Defic Syndr 2005;38(Suppl 1):36-37.

(3) Scott GB, Fischl MA, Klimas N, et al. Mothers of infants with the acquired immunodeficiency syndrome. JAMA 1985;253(3):363-66; Minkoff H, Ragt RH, Landesman S, et al. Pneumocystis carinii pneumonia associated with acquired immunodeficiency syndrome in pregnancy: a report of three maternal deaths. Obstet Gynecol 1986;67(2):284; Minkoff H, Nanda D, Menez R, et al. Pregnancies resulting in infants with acquired immunodeficiency syndrome or AIDS-related complex: follow-up of mothers, children, and subsequently born siblings. Obstet Gynecol 1987;69(3 Part 1):288-91; Koonin LM, Ellerbrock RV, Atrash HK, et al. Pregnancy-associated deaths due to AIDS in the United States. JAMA 1989;261(10):1306-9; Lindgren A, Anzen B, Bohlin AB, et al. HIV and childbearing: clinical outcome and aspects of mother to infant transmission. AIDS 1991;5(9):1111-16.

(4) French R, Brocklehurst P. The effect of pregnancy on survival in women infected with HIV: a systematic review of the literature and meta-analysis. Br J Obstet Gynaecol 1998;105(8):827-35.

(5) Saada M, Le Chenadec J, Berrebi A, et al. Pregnancy and progression to AIDS: results of the French prospective cohorts. AIDS 2000;14(15):2355-60.

(6) Hocke C, Morlat P, Chene G, et al. Prospective cohort study of the effect of pregnancy on the progression of human immunodeficiency virus infection. The Groupe d'Epidemiologie Clinique du SIDA en Aquitaine. Obstet Gynecol 1995;86(6):886-91; Weisser M, Rudin C, Battlegay M, et al. Does pregnancy influence the course of HIV infection? Evidence from two large Swiss cohort studies. J Acquir Immune Defic Syndr 1998;17(5):404-10; Burns DN, Landesman S, Minkoff H, et al. The influence of pregnancy on human immunodeficiency virus type 1 infection: antepartum and postpartum changes in human immunodeficiency virus type 1 viral load. Am J Obstet Gynecol 1998; 178(2):355-59; Brettle RP, Raab GM, Ross A, et al. HIV infection in women: immunological markers and the influence of pregnancy. AIDS 1995;9(10):1177-84.

(7) Deschamps M, Pape J, Desvarieux M, et al. A prospective study of HIV-seropositive asymptomatic women of childbearing age in a developing country. J Acquir Immune Defic Syndr 1993;6(5):446-51.

(8) Temmerman M, Nagelkerke N, Bwayo J, et al. HIV-1 and immunological changes during pregnancy: a comparison between HIV-1 seropositive and HIV-1 seronegative women in Nairobi, Kenya. AIDS 1995;9(9):1057-60; Miotti P, Liomba G, Dallabetta GA, et al. T-lymphocyte subsets during and after pregnancy: analysis in human immunodeficiency virus type-1-infected and uninfected Malawian mothers. J Infect Dis 1992;165(6):1116-19.
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Title Annotation:Hormonal Contraceptive Use by HIV-infected Women
Author:Shears, Kathleen Henry
Publication:Network
Date:Jun 22, 2007
Words:918
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