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Two million babies born too soon and too small due to HIV in Africa in the past three decades

NPEU

A new study by researchers from Oxford Population Health estimates, for the first time, that two million babies were born too soon and too small due to HIV and its treatment in sub-Saharan Africa during the period 1990-2020. The study is published in Communications Medicine.

Sub-Saharan Africa has the highest neonatal and childhood mortality rates in the world. Most of the countries in this region will not reach the United Nations Sustainable Development Goals for reducing neonatal and childhood mortality by 2030. Adverse pregnancy outcomes such as babies being born too soon (premature birth before 37 weeks’ gestation), babies born too small (birthweight below 2.5 kg), or small-for-gestational-age (smaller than expected based on weeks of pregnancy), are major contributors to death and disease in childhood.

Each year, 1.3 million women living with HIV are pregnant, the majority of whom live in sub-Saharan African countries. The researchers identified how many adverse pregnancy outcomes were associated with babies born to women living with HIV in this region, including those receiving antiretroviral therapy, to inform health strategies and improve health outcomes for women living with HIV and their children.

Key findings:

  • Women living with HIV who did not receive any treatment or who received triple drug combination antiretroviral therapy (cART), the standard treatment for HIV infection, started before or during pregnancy had an increased risk of giving birth prematurely (6.4% excess risk for women not receiving treatment; 6.5% for women who were receiving pre-conception cART; 2.8% for women receiving cART antenatally), having a baby with low birthweight (7.3% in women not receiving treatment; 4% in women who receiving pre-conception cART, 5.5% in women receiving cART antenatally), and having a baby smaller than expected for their gestational age (6.1% in women not receiving treatment; 5.3% in women received pre-conception cART; 3.8% in women receiving cART antenatally), when compared with HIV negative women. The outcomes were assessed separately, but babies may have more than one of these outcomes;
  • The increased risks of adverse outcomes were highest among women living with HIV who were not receiving treatment. Women living with HIV who received cART had lower risks of adverse pregnancy outcomes compared to those not receiving treatment, and thereby averted many adverse outcomes, but risks remained substantially higher than for HIV negative women. Women living with HIV who received monotherapy (which is no longer recommended) had the lowest risks, similar to HIV negative women;
  • Between 1990 and 2020, 1,921,563 babies born prematurely, 2,119,320 babies born with a low birth weight, and 2,049,434 babies born smaller than expected for their gestational age could be attributed to HIV and antiretroviral therapy in sub-Saharan Africa, with the majority born to women living with HIV who did not receive treatment;
  • In 2020, 64,585 babies born prematurely, 58,608 babies with a low birth weight, and 61,112 babies who were smaller than expected for their gestational age were estimated to be attributable to HIV and antiretroviral therapy, with the majority born to women living with HIV who received cART from before they became pregnant;
  • As more women living with HIV in sub-Saharan Africa are receiving cART from before pregnancy, the burden of adverse pregnancy outcomes among women living with HIV in sub-Saharan Africa is likely to remain high.

Dr Joris Hemelaar, senior author of the study, said ‘We have estimated for the first time the number of excess adverse pregnancy outcomes attributable to HIV and its treatments in sub-Saharan Africa, the region most affected by the HIV pandemic. We found that HIV and its treatments contributed significantly to the burden of adverse pregnancy outcomes in sub-Saharan Africa in 1990–2020.

‘An increasing proportion of women living with HIV receive triple drug antiretroviral therapy from before pregnancy, which has clear benefits for maternal health and prevention of HIV transmission to the child. However, we found that triple drug antiretroviral therapy started before pregnancy is associated with increased risks of adverse pregnancy outcomes among women living with HIV, compared to HIV-negative women.

‘Further studies are therefore urgently needed to determine the optimal triple drug regimen(s) to minimise adverse pregnancy outcomes, and develop preventative and therapeutic interventions to improve pregnancy outcomes among women living with HIV.’ 

The researchers also note that monotherapy and cART averted many adverse health outcomes for mothers and babies. Since 2013, triple drug cART has been recommended for the treatment of pregnant women living with HIV due to improved long-term health outcomes.