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Research Letters |

Pregnancy Incidence and Outcomes in Vertically and Behaviorally HIV-Infected Youth FREE

Allison L. Agwu, MD, ScM; Susie S. Jang, MD; P. Todd Korthuis, MD, MPH; Maria Rosario G. Araneta, PhD; Kelly A. Gebo, MD, MPH
JAMA. 2011;305(5):468-470. doi:10.1001/jama.2011.79.
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Published online

To the Editor: Human immunodeficiency virus (HIV)–infected youth are reaching child-bearing age because of treatment with highly active antiretroviral therapy (HAART).1 We hypothesized that given different risk behaviors, vertically infected youth (VIY) may have differences in pregnancy rates and adverse outcomes compared with behaviorally infected youth (BIY).

This was a retrospective study of all female VIY aged 13 to 24 years and all female BIY from clinic enrollment through age 24 years followed up between January 1997 and May 2009 at 4 high-volume, urban, academic pediatric clinics in the HIV Research Network.2 Median age of first inclusion was 13 years (interquartile range [IQR], 13-13 years) for VIY and 17.4 years (IQR, 13.8-20.1 years) for BIY. We examined pregnancies occurring in the setting of known HIV infection; 7 pregnancies where HIV was diagnosed concurrently were excluded. All sites had institutional review board approval. Written informed consent was obtained at enrollment at 1 site that required it; other sites waived the requirement.

Group characteristics were compared with χ2 tests. The main outcome measures included pregnancy incidence, delivery outcomes (live birth, spontaneous abortion, therapeutic abortion) and adverse pregnancy outcomes (prematurity and stillbirth). Poisson regression was used to compare pregnancy incidence rates. Univariate logistic regression was used to compare groups in terms of pregnancy outcomes of live births and stillbirths among pregnancies excluding therapeutic abortions and preterm delivery among live births. Clustering by patient adjusted for multiple pregnancies per patient. A P value less than .05 was considered significant. Statistical analyses were done with Stata 10.0 (StataCorp, College Station, Texas).

Of 181 HIV-infected female youth, 130 VIY and 51 BIY were followed up for 637.2 patient-years (VIY: median, 8.9; range, 5.7-10.3 patient-years per patient; BIY: median, 1.6; range, 0.4-3.2 patient-years per patient). Overall, 66 youth had 96 pregnancies (34 among VIY, 62 among BIY). Twenty-eight VIY (21.5%) and 38 BIY (74.5%) had 1 or more pregnancies (P < .001). Incidence rates were 52.3 pregnancies per 1000 patient-years among VIY and 372.9 pregnancies per 1000 patient-years among BIY (P < .001). Of the 66 females who became pregnant, 72.7% had 1 pregnancy, 15.1% had 2 pregnancies, 9.1% had 3 pregnancies, and 3.0% had 4 or more pregnancies. Behaviorally infected youth tended to have more than 1 pregnancy compared with VIY (36.8% vs 14.3%, P = .04).

The median age at first pregnancy was 18 years in VIY and 19.5 years in BIY (P = .06) (Table 1). Pregnant VIY were more likely than BIY to have a CD4 count less than 200/μL as prepregnancy nadir (35.7% vs 7.5%, P = .01) and at delivery (28.6% vs 5.0%, P = .04). Prenatal HAART use and HIV-1 RNA levels were similar between BIY and VIY pregnancies. No other differences were associated with incident pregnancy between the groups (Table 1).

Table Graphic Jump LocationTable 1. Demographic and Clinical Characteristics of Pregnant VIY and BIY Females (N = 66)

Pregnant VIY were more likely than BIY to electively terminate (41.2% vs 9.7%, P = .001). There were no differences in adverse pregnancy outcomes between the groups (Table 2). One-third of live births were premature (29.4% VIY, 36.3% BIY), 13.5% of pregnancies ended in spontaneous abortion (5.9% VIY, 17.7% BIY), and 2.1% ended in stillbirth (2.9% VIY, 1.6% BIY). Vertical transmission occurred in 1 live birth in a BIY despite prenatal HAART.

Table Graphic Jump LocationTable 2. Comparison of Pregnancy Outcomes Between VIY and BIY Pregnancies

In this cohort, we observed high pregnancy incidence among VIY and BIY. The rates in BIY were 5 and 2.5 times those in the general population aged 15 to 19 and 20 to 24 years, respectively.3 The reasons for the observed rates, particularly among BIY, may be multifactorial. Behaviorally infected youth may have other characteristics that were not studied (eg, pregnancy desire) that increased pregnancy risk. Compared with nationally observed data in youth, there were higher rates of premature births (34.4% vs 21.5%) and spontaneous abortions (13.5% vs 8.9%).4,5 Vertically infected youth were more likely than BIY to electively terminate pregnancy.

Our findings are not generalizable to all clinics caring for HIV-infected youth. The study is limited by its retrospective nature, small numbers, and limited follow-up time for BIY.

Early risk reduction to prevent unplanned pregnancies among HIV-infected youth is critical. Studies to understand differences in reproductive attitudes and decision making between VIY and BIY are vital to optimizing counseling and medical care for this population.

Author Contributions: Dr Agwu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Agwu, Jang, Korthuis, Araneta, Gebo.

Acquisition of data: Jang, Korthuis, Araneta, Gebo.

Analysis and interpretation of data: Agwu, Jang, Korthuis, Araneta, Gebo.

Drafting of the manuscript: Agwu, Jang.

Critical revision of the manuscript for important intellectual content: Agwu, Korthuis, Araneta, Gebo.

Statistical analysis: Agwu, Jang, Araneta.

Obtained funding: Gebo.

Administrative, technical, or material support: Gebo.

Study supervision: Agwu, Gebo.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Gebo reported having consulted, having served on a scientific advisory board, and having received research funding from Tibotec. No other disclosures were reported.

Funding/Support: This study was supported by the Agency for Healthcare Research and Quality (AHRQ) (290-01-0012) and the National Institute on Aging (R01 AG026250) (K.A.G.). Dr Agwu was supported by the National Center for Research Resources (NCCR), a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research (1KL2RR025006-01), and by the National Institute of Allergy and Infectious Diseases (1K23AI084549). Dr Jang was supported by a grant from the Doris Duke Charitable Foundation to Johns Hopkins University School of Medicine. Dr Korthuis was supported by the National Institute on Drug Abuse (K23-DA019809).

Role of the Sponsors: The funding agencies had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Participating Sites: Alameda County Medical Center, Oakland, California (Howard Edelstein, MD); Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Richard Rutstein, MD); Community Health Network, Rochester, New York (Roberto Corales, DO); Drexel University, Philadelphia (Jeffrey Jacobson, MD; Sara Allen, CRNP); Johns Hopkins University, Baltimore, Maryland (Kelly Gebo, MD; Richard Moore, MD; Allison Agwu, MD); Montefiore Medical Group, Bronx, New York (Robert Beil, MD; Carolyn Chu, MD); Montefiore Medical Center, Bronx (Lawrence Hanau, MD); Nemechek Health Renewal, Kansas City, Missouri (Patrick Nemechek, MD); Oregon Health and Science University, Portland (P. Todd Korthuis, MD); Parkland Health and Hospital System, Dallas, Texas (Gary Sinclair, MD; Laura Armas-Kolostroubis, MD); St Jude's Children's Hospital and University of Tennessee, Memphis (Aditya Gaur, MD); St Luke's Roosevelt Hospital Center, New York, New York (Victoria Sharp, MD); Tampa General Health Care, Tampa, Florida (Charurut Somboonwit, MD); University of California, San Diego, La Jolla (Stephen Spector, MD); University of California, San Diego (W. Christopher Mathews, MD); Wayne State University, Detroit, Michigan (Jonathan Cohn, MD).

Sponsoring Agencies: Agency for Healthcare Research and Quality, Rockville, Maryland (Fred Hellinger, PhD; John Fleishman, PhD; Irene Fraser, PhD); Health Resources and Services Administration, Rockville (Robert Mills, PhD).

Data Coordinating Center: Johns Hopkins University (Richard Moore, MD; Jeanne Keruly, CRNP; Kelly Gebo, MD; Cindy Voss, MA; Bonnie Cameron, MS).

Disclaimer: The views expressed in this article are those of the authors. No official endorsement by the AHRQ or NCCR is intended or should be inferred.

Additional Contributions: We would like to acknowledge Robert Warford, PA, St Luke’s-Roosevelt, for his diligence in verifying the data from his site and John Fleishman, PhD, AHRQ, for his careful review of the manuscript. Neither received compensation for the contributions.

Gortmaker SL, Hughes M, Cervia J,  et al; Pediatric AIDS Clinical Trials Group Protocol 219 Team.  Effect of combination therapy including protease inhibitors on mortality among children and adolescents infected with HIV-1.  N Engl J Med. 2001;345(21):1522-1528
PubMed   |  Link to Article
Fleishman JA, Gebo KA, Reilly ED,  et al; HIV Research Network.  Hospital and outpatient health services utilization among HIV-infected adults in care 2000-2002.  Med Care. 2005;43(9):(suppl)  III40-III52
PubMed
Ventura SJ, Abma JC, Mosher WD, Henshaw SK. Estimated pregnancy rates by outcome for the United States, 1990-2004.  Natl Vital Stat Rep. 2008;56(15):1-25
PubMed
Chen XK, Wen SW, Fleming N, Demissie K, Rhoads GG, Walker M. Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort study.  Int J Epidemiol. 2007;36(2):368-373
PubMed   |  Link to Article
Nybo Andersen AM, Wohlfahrt J, Christens P, Olsen J, Melbye M. Maternal age and fetal loss: population based register linkage study.  BMJ. 2000;320(7251):1708-1712
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Demographic and Clinical Characteristics of Pregnant VIY and BIY Females (N = 66)
Table Graphic Jump LocationTable 2. Comparison of Pregnancy Outcomes Between VIY and BIY Pregnancies

References

Gortmaker SL, Hughes M, Cervia J,  et al; Pediatric AIDS Clinical Trials Group Protocol 219 Team.  Effect of combination therapy including protease inhibitors on mortality among children and adolescents infected with HIV-1.  N Engl J Med. 2001;345(21):1522-1528
PubMed   |  Link to Article
Fleishman JA, Gebo KA, Reilly ED,  et al; HIV Research Network.  Hospital and outpatient health services utilization among HIV-infected adults in care 2000-2002.  Med Care. 2005;43(9):(suppl)  III40-III52
PubMed
Ventura SJ, Abma JC, Mosher WD, Henshaw SK. Estimated pregnancy rates by outcome for the United States, 1990-2004.  Natl Vital Stat Rep. 2008;56(15):1-25
PubMed
Chen XK, Wen SW, Fleming N, Demissie K, Rhoads GG, Walker M. Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort study.  Int J Epidemiol. 2007;36(2):368-373
PubMed   |  Link to Article
Nybo Andersen AM, Wohlfahrt J, Christens P, Olsen J, Melbye M. Maternal age and fetal loss: population based register linkage study.  BMJ. 2000;320(7251):1708-1712
PubMed   |  Link to Article
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