High Incidence of Unplanned Pregnancy after Antiretroviral Therapy Initiation: Findings from a Prospective Cohort Study in South Africa

Increased fertility rates in HIV-infected women receiving antiretroviral therapy (ART) have been attributed to improved immunological function; it is unknown to what extent the rise in pregnancy rates is due to unintended pregnancies.Non-pregnant women ages 18-35 from four public-sector ART clinics in Johannesburg, South Africa, were enrolled into a prospective cohort and followed from August 2009-March 2011. Fertility intentions, contraception and pregnancy status were measured longitudinally at participants' routine ART clinic visits.Of the 850 women enrolled, 822 (97%) had at least one follow-up visit and contributed 745.2 person-years (PY) at-risk for incident pregnancy. Overall, 170 pregnancies were detected in 161 women (incidence rate [IR]: 21.6/100 PY [95% confidence interval (CI): 18.5-25.2]). Of the 170 pregnancies, 105 (62%) were unplanned. Unmet need for contraception was 50% higher in women initiating ART in the past year as compared to women on ART>1 year (prevalence ratio 1.5 [95% CI: 1.1-2.0]); by two years post-ART initiation, nearly one quarter of women had at least one unplanned pregnancy. Cumulative incidence of pregnancy was equally high among recent ART initiators and ART experienced participants: 23.9% [95% CI: 16.4-34.1], 15.9% [12.0-20.8], and 21.0% [16.8-26.1] for women on ART 0-1 yr, >1 yr-2 yrs, and >2 yrs respectively (log-rank, p = 0.54). Eight hormonal contraceptive failures were detected [IR: 4.4 [95% CI: 2.2-8.9], 7/8 among women using injectable methods. Overall 47% (80/170) of pregnancies were not carried to term.Rates of unintended pregnancies among women on ART are high, including women recently initiating ART with lower CD4 counts and higher viral loads. A substantial burden of pregnancy loss was observed. Integration of contraceptive services and counselling into ART care is necessary to reduce maternal and child health risks related to mistimed and unwanted pregnancies. Further research into injectable contraceptive failures on ART is warranted

Infections of the Central Nervous System and Child Development in Sub-Saharan Africa

Abstract: Infectious diseases contribute significantly to child mortality in Africa; however, mortality rates only represent part of the problem. Among those who survive, cognitive, educational, and behavioral impairments have been reported. In the current chapter, I highlight the neurocognitive deficits, mental health problems, and poor educational outcomes associated with exposure to infectious diseases early in life. Special attention is paid to outcomes of HIV-infected children and children exposed to malaria. The chapter concludes by highlighting two approaches to intervention that have been observed to remediate some of the adverse effects of exposure to infections. Given the prevalence of infectious diseases in the African context, there are huge adverse effects and loss in human potential associated with childhood infectious diseases; identifying points of interventions and implementing evidence-based intervention for children infected with these conditions need to be a priority for applied developmental sciences