Effect of HIV infection on pregnancy-related mortality in sub-Saharan Africa: secondary analyses of pooled community based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA)

Zaba, B., Calvert, C., Marston, M., Isingo, R., Nakiyingi-Miiro, J., Lutalo, T., Crampin, A., Robertson, L., Herbst, K., Newell, M.L., Todd, J., Byass, P., Boerma, T. and Ronsmans, C. (2013) Effect of HIV infection on pregnancy-related mortality in sub-Saharan Africa: secondary analyses of pooled community based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA). The Lancet, 381 (9879), 1763-1771. (doi:10.1016/S0140-6736(13)60803-X). (PMID:23683643)

Abstract

BACKGROUND: Model-based estimates of the global proportions of maternal deaths that are in HIV-infected women range from 7% to 21%, and the effects of HIV on the risk of maternal death is highly uncertain. We used longitudinal data from the Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) network to estimate the excess mortality associated with HIV during pregnancy and the post-partum period in sub-Saharan Africa.

METHODS: The ALPHA network pooled data gathered between June, 1989 and April, 2012 in six community-based studies in eastern and southern Africa with HIV serological surveillance and verbal-autopsy reporting. Deaths occurring during pregnancy and up to 42 days post partum were defined as pregnancy related. Pregnant or post-partum person-years were calculated for HIV-infected and HIV-uninfected women, and HIV-infected to HIV-uninfected mortality rate ratios and HIV-attributable rates were compared between pregnant or post-partum women and women who were not pregnant or post partum.

FINDINGS: 138,074 women aged 15-49 years contributed 636,213 person-years of observation. 49,568 women had 86,963 pregnancies. 6760 of these women died, 235 of them during pregnancy or the post-partum period. Mean prevalence of HIV infection across all person-years in the pooled data was 17.2% (95% CI 17.0-17.3), but 60 of 118 (50.8%) of the women of known HIV status who died during pregnancy or post partum were HIV infected. The mortality rate ratio of HIV-infected to HIV-uninfected women was 20.5 (18.9-22.4) in women who were not pregnant or post partum and 8.2 (5.7-11.8) in pregnant or post-partum women. Excess mortality attributable to HIV was 51.8 (47.8-53.8) per 1000 person-years in women who were not pregnant or post partum and 11.8 (8.4-15.3) per 1000 person-years in pregnant or post-partum women.

INTERPRETATION: HIV-infected pregnant or post-partum women had around eight times higher mortality than did their HIV-uninfected counterparts. On the basis of this estimate, we predict that roughly 24% of deaths in pregnant or post-partum women are attributable to HIV in sub-Saharan Africa, suggesting that safe motherhood programmes should pay special attention to the needs of HIV-infected pregnant or post-partum women.

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Contributors

Author: M.L. Newell

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