live birth patterns among human immunodeficiency virus-infected women before and after the...
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BSTETRICS
ive birth patterns among human immunodeficiency virus-nfected women before and after the availability of highlyctive antiretroviral therapy
njali Sharma, MD, MS; Joseph G. Feldman, DrPh; Elizabeth T. Golub, PhD; Julie Schmidt, MD; Sylvia Silver, DA;sther Robison, PhD; Howard Minkoff, MD
BJECTIVE: The objective of the study was to investigate the relation-hip between human immunodeficiency virus (HIV) infection andhildbearing before and after the availability of highly active antiretro-iral therapy (HAART).
ETHODS: Enrollment in the Women’s Interagency HIV study tooklace in 1994-1995 (pre-HAART era) and again in 2001-2002 (HAARTra). Live birth rates prior to enrollment were compared between treat-ent era cohorts for HIV-infected and HIV-uninfected women aged
5-44 years using Poisson regression. For HIV-infected women, wencluded live births between HIV diagnosis date and study entry; theAART era cohort included only women diagnosed with HIV in 1996
oi: 10.1016/j.ajog.2007.01.005
ESULTS: Among HIV-infected women, the HAART era live birth rateas 150% higher than in the pre-HAART era (P � .001) vs a 5%
ncrease among HIV-uninfected women. The rate of increase in liveirth rate was higher for women �35 years old (vs younger than 25ears, P � .02), and with more than a high school education (vs. lesshan high school, P � .05).
ONCLUSION: The availability of effective therapeutic interventionsas had a profound impact on child-bearing among HIV-infectedomen.
ey words: birth rate, highly active antiretroviral therapy, human
nd afterward. immunodeficiency virus, reproductive decision making, womenite this article as: Sharma A, Feldman JG, Golub ET, et al. Live birth patterns among human immunodeficiency virus-infected women before and after thevailability of highly active antiretroviral therapy. Am J Obstet Gynecol 2007;196;541.e1-541.e6.
he number of women living withhuman immunodeficiency virus
HIV) infection and acquired immuno-eficiency syndrome (AIDS) has been
ncreasing steadily worldwide, andomen now account for approximately
50% of the 40 million adults living withHIV/AIDS globally.1 In the United Statesduring 2001-2004, an estimated 45,146women had HIV/AIDS diagnosed in the33 states reporting to the Centers for Dis-ease Control and Prevention, 75% of
whom were aged 13-44 years.2 Becausethe majority of HIV-infected women arein the years of highest fertility, it is im-portant to understand the interplay be-tween their reproductive activities andHIV serostatus and the factors that influ-ence child-bearing decisions.
Since 1996, highly active antiretroviraltherapy (HAART) has been available inthe United States and has been shown todramatically improve survival for indi-viduals with HIV and to markedly re-duce the rate of mother-to-child trans-mission of HIV.3-6 However, it is unclearwhether these advantages have affectedwomen’s child-bearing plans. Studiesconducted prior to the widespread avail-ability of HAART have revealed that HIVinfection per se had not been a barrier topregnancy, although often the pregnan-cies occurred coincident with the diag-nosis of HIV infection.7-9 In this report,we capitalize on a large cohort study ofHIV-infected and at-risk women that re-cruited women of similar ages, back-grounds, and ethnicities in 2 waves: 1 be-
rom the Departments of Infectious Diseases (Dr Sharma) and Epidemiology (Dreldman), State University of New York Downstate Medical Center, Brooklyn, NY; theepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health,altimore, MD (Dr Golub); the Department of Obstetrics and Gynecology, John H. Stroger
r Hospital of Cook County, Chicago, IL (Dr Schmidt); the Department of Pathology,eorge Washington University Medical Center, Washington, DC (Ms Silver); theepartment of Epidemiology, Montefiore Medical Center, Bronx, NY (Dr Robison); and
he Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NYDr Minkoff).
eceived Sept. 18, 2006; revised Dec. 7, 2006; accepted Jan. 2, 2007.
eprints: Anjali Sharma, State University of New York Downstate Medical Center, 450 Clarksonve, Box 1240, Brooklyn, NY 11203; [email protected].
he Women’s Interagency HIV Study is funded by the National Institute of Allergy and Infectiousiseases with supplemental funding from the National Cancer Institute, the National Institute onrug Abuse (UO1-AI-35004, UO1-AI-31834, UO1-AI-34994, UO1-AI-34989, UO1-AI-34993,nd UO1-AI-42590). Funding is also provided by the National Institute of Child Health anduman Development (UO1-HD-32632) and the National Center for Research Resources (MO1-R-00071, MO1-RR-00079, MO1-RR-00083).
002-9378/$32.002007 Mosby, Inc. All rights reserved.
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ore and 1 after HAART became
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vailable, to compare the influence ofIV infection on child-bearing in 2 eras
racketed by the availability of effectiveherapeutic interventions.
ATERIALS AND METHODShe Women’s Interagency HIV Study
WIHS) is an ongoing prospective studyf the natural history of HIV infection inomen; 2056 HIV seroprevalent and 569
eronegative participants were enrolledt 6 clinical consortia (Bronx, NY;rooklyn, NY; Chicago, IL; San Fran-isco, CA; Los Angeles, CA; and Wash-ngton, DC) between October 1994 and
ovember 1995. A second wave of re-ruitment at the same sites took place be-ween October 2001 and November 2002nrolling an additional 738 seropositive254 HAART-naïve; 484 HAART-expe-ienced) and 406 seronegative women.
The recruitment methods and dataollection procedures of the WIHS haveeen previously described.10 Briefly, par-icipants undergo semiannual visits thatnclude an interviewer-administereduestionnaire, a physical examination,nd the collection of blood and gyneco-ogic specimens. Marital status, educa-ion level, annual income, and HIV-ex-osure category were determined fromelf-report at baseline. Depressive symp-oms were assessed using the Center forpidemiologic Studies Depression ScaleCES-D), with those scoring 16 orreater classified as depressed.11
At their baseline visit, all partici-ants were asked when they first
earned of their HIV serostatus. Thisnalysis focused on live birth rates be-ween the first HIV-positive test andtudy entry. For seronegative controls,e included live births that occurredetween the ages of 15 and 44 years,rior to study enrollment. Womenere considered to be at risk for preg-ancy if they were of reproductive age15-44 years) and had not undergone aysterectomy or sterilization.Periods corresponding to treatment era
ere used to examine population effects ofAART availability on HIV-infectedomen. Thus, we were assessing whethereing HIV infected at a time when HAART
as available, whether or not individual w41.e2 American Journal of Obstetrics & Gynecol
omen used it, influenced reproductiveecision making. The initial recruitmenthase was defined as the pre-HAART eraohort, and the second recruitment phaseas defined as HAART era cohort becauseAART was widely available during this
ime frame. Live birth rates were the num-er of reported live births per 1000 person-ears and were compared between the pre-AART and HAART era cohorts.For HIV-infected women in theAART era cohort, only those who
ested HIV positive in 1996 or later werencluded. Person-years of exposure forhe HIV-infected women included theumber of years between the date of therst positive HIV test and the date oftudy enrollment. Person-years of expo-ure for the HIV-uninfected women in-luded the number of years between age5 years and the age at study enrollmentr up to age 44 years.
tatistical analysise compared differences in the live
irth rates between the pre-HAART andAART era cohorts for HIV-infected
nd uninfected women using Poisson re-ression models, using log person-yearso represent follow-up time. The modelsere scaled using the Pearson Q statisticivided by its degrees of freedom12. In-eractions between cohort (pre-HAARTs HAART era) and HIV serostatus werexamined after adjusting for follow-upime and selected covariates, such as age,ace/ethnicity, education, HIV exposureisk category, and depressive symptoms.
Reported P values (shown in Table 2)efer to the level of statistical significanceor these interactions. Changes in liveirth rate between the cohorts by HIVerostatus were assessed for statisticalignificance. Goodness-of-fit measuresere obtained and were adequate for
ach model examined. Analyses wereonducted using SAS version 9.1 soft-are (SAS Institute, Cary, NC).
ESULTSaseline characteristics for WIHS partic-
pants in the pre-HAART (1994-1995)nd the HAART era (2001-2002) cohortsre shown in Table 1. The majority of
omen in both cohorts were of racial or oogy JUNE 2007
thnic minority background and re-orted an annual income of less than12,000. WIHS participants recruited inhe HAART era were slightly youngermedian age 33 years for HIV-positivend 29 years for HIV-negative women inhe HAART era cohort vs 36 years forIV-positive and 34 years for HIV-neg-
tive women in the pre-HAART cohort).hey also had higher baseline CD4ounts, with 9.2% of HIV-infectedomen having CD4 counts below 200
ells/mm3 in the HAART era cohort vs9% in the pre-HAART cohort.Of 2056 HIV seroprevalent women
nrolled in the pre-HAART cohort, 201297.9%) were at risk for pregnancy andontributed 7573 person-years of data.ll 569 seronegative women enrolled in
he pre-HAART cohort were at risk forregnancy and contributed 10,673 per-on-years of data. An additional 738 HIVeroprevalent women were enrolled in001-2002 as part of the HAART era co-ort, and of these, 476 were at risk forregnancy in 1996 and after and contrib-ted 1326 person-years of data. Of thedditional 406 seronegative women en-olled in the HAART era cohort, all but 1ere at risk for pregnancy, contributing930 person-years of data.For both the HIV-infected and unin-
ected women, the live birth rates in theAART era were higher than those dur-
ng the pre-HAART era; however, thisifference was much more pronouncedmong HIV-infected women (Table 2)mong HIV-uninfected women, the to-
al live birth rate per 1000 person-yearsas only 5% higher in the HAART era
han the pre-HAART era, whereas foromen with HIV, the rate increased by50% (P � .001). Results of the multi-ariate analysis are shown in Table 2; thevalue represents the significance of the
hange in birth rate between the cohortsy serostatus, for each covariate, afterdjusting for age, race/ethnicity, educa-ion, exposure category, and CES-Dcore.
Among HIV-infected women, the liveirth rate was higher in the HAART erahan it had been in the pre-HAART eran all age categories, with the largest dif-erence (306%) seen among women
lder than 35 years of age. In the pre-
www.AJOG.org Obstetrics Research
TABLE 1Baseline WIHS participant charact
Pre
HIVn �
Age, y*..........................................................................................................
Younger than 25 71..........................................................................................................
25-29 97..........................................................................................................
30-34 113..........................................................................................................
35� 275...................................................................................................................
Marital status..........................................................................................................
Married 146..........................................................................................................
Living with partner 96..........................................................................................................
Widowed 29..........................................................................................................
Divorced 42..........................................................................................................
Separated 62..........................................................................................................
Never married 190..........................................................................................................
Other 4...................................................................................................................
Annual income..........................................................................................................
Less than $12,000 338..........................................................................................................
$12,000-24,0000 104..........................................................................................................
$24,001-36,000 50..........................................................................................................
More than $36,000 43...................................................................................................................
Depression (CES-D)..........................................................................................................
16 or greater 306...................................................................................................................
Education completed..........................................................................................................
Less than high school 210..........................................................................................................
High school 183..........................................................................................................
More than high school 176...................................................................................................................
Race..........................................................................................................
White non-Hispanic 89..........................................................................................................
Hispanic 158..........................................................................................................
African American 303..........................................................................................................
Other 19...................................................................................................................
Exposure category..........................................................................................................
Injection drug use 158..........................................................................................................
Heterosexual 145..........................................................................................................
Transfusion† 15..........................................................................................................
Unknown 246...................................................................................................................
Lifetime number of sexual partners..........................................................................................................
0-4 262..........................................................................................................
5-10 138..........................................................................................................
11-100 140..........................................................................................................
More than 100 29
eristics in the pre-HAART- and HAART-era cohorts-HAART cohort HAART-era cohort
�569 (%)
HIV�n � 2012 (%) P value
HIV�n � 405 (%)
HIV�n � 476 (%) P value
�.01 .03.............................................................................................................................................................................................................................................................
(12.8) 293 (14.6) 140 (34.7) 144 (30.3).............................................................................................................................................................................................................................................................
(17.4) 462 (23.0) 77 (19.1) 124 (26.1).............................................................................................................................................................................................................................................................
(20.3) 508 (25.3) 78 (19.4) 104 (21.9).............................................................................................................................................................................................................................................................
(49.5) 743 (37.0) 108 (26.8) 103 (21.7).............................................................................................................................................................................................................................................................
�.01 �.01.............................................................................................................................................................................................................................................................
(25.7) 435 (21.6) 77 (19.0) 116 (24.4).............................................................................................................................................................................................................................................................
(16.9) 287 (14.3) 41 (10.1) 68 (14.3).............................................................................................................................................................................................................................................................
(5.1) 204 (10.1) 6 (1.5) 12 (2.5).............................................................................................................................................................................................................................................................
(18.3) 228 (11.3) 26 (6.4) 28 (5.9).............................................................................................................................................................................................................................................................
(10.9) 234 (11.6) 23 (5.7) 40 (8.4).............................................................................................................................................................................................................................................................
(33.4) 607 (30.2) 210 (51.9) 192 (30.4).............................................................................................................................................................................................................................................................
(0.7) 15 (0.7) 22 (5.4) 19 (4.0).............................................................................................................................................................................................................................................................
.87 .33.............................................................................................................................................................................................................................................................
(63.2) 1226 (63.2) 212 (52.9) 247 (52.7).............................................................................................................................................................................................................................................................
(19.4) 393 (20.3) 77 (19.2) 108 (23.0).............................................................................................................................................................................................................................................................
(9.3) 180 (9.3) 56 (14.0) 61 (13.0).............................................................................................................................................................................................................................................................
(8.0) 140 (7.2) 56 (14.0) 53 (11.3).............................................................................................................................................................................................................................................................
.48 .70.............................................................................................................................................................................................................................................................
(55.0) 1129 (57.7) 170 (42.4) 199 (42.6).............................................................................................................................................................................................................................................................
.92 .15.............................................................................................................................................................................................................................................................
(36.9) 744 (37.0) 141 (35.6) 192 (40.7).............................................................................................................................................................................................................................................................
(32.2) 629 (31.3) 115 (29.0) 122 (25.8).............................................................................................................................................................................................................................................................
(30.9) 639 (31.8) 140 (35.4) 158 (33.5).............................................................................................................................................................................................................................................................
.11 .02.............................................................................................................................................................................................................................................................
(15.6) 370 (18.4) 49 (12.1) 29 (6.1).............................................................................................................................................................................................................................................................
(27.8) 471 (23.4) 115 (28.5) 152 (32.0).............................................................................................................................................................................................................................................................
(53.3) 1116 (55.5) 224 (55.4) 271 (57.1).............................................................................................................................................................................................................................................................
(3.3) 55 (2.7) 16 (4.0) 23 (4.8).............................................................................................................................................................................................................................................................
�.01 �.01.............................................................................................................................................................................................................................................................
(28.0) 671 (33.6) 51 (12.6) 40 (8.5).............................................................................................................................................................................................................................................................
(25.7) 839 (42.1) 97 (24.0) 190 (40.2).............................................................................................................................................................................................................................................................
(2.7) 79 (4.0) —† —†
.............................................................................................................................................................................................................................................................
(43.6) 406 (20.4) 256 (63.4) 243 (51.4).............................................................................................................................................................................................................................................................
.05 �.01.............................................................................................................................................................................................................................................................
(46.1) 946 (47.0) 81 (20.1) 146 (31.1).............................................................................................................................................................................................................................................................
(24.1) 466 (23.2) 126 (31.3) 164 (34.9).............................................................................................................................................................................................................................................................
(24.8) 434 (21.6) 160 (39.7) 145 (30.9).............................................................................................................................................................................................................................................................
(5.1) 165 (8.2) 36 (8.9) 15 (3.2)................................................................................................................................................................................................................................................................................................................................................................................
* Age at time of HIV diagnosis or age at study enrollment for HIV-uninfected women.†
Transfusion risk not assessed in HAART-era cohort.
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Research Obstetrics www.AJOG.org
5
AART era, HIV-infected women hadower live birth rates than HIV-unin-ected women in every age category;owever, in the HAART era, HIV-in-
ected women younger than 30 years ofge had higher birth rates, comparedith HIV-uninfected women, womenetween ages 30 and 34 years had similarirth rates by serostatus, and HIV-in-ected women aged 35 years and olderad lower birth rates, compared withIV-uninfected women. The difference
n birth rate by HIV status was significantnly when comparing women youngerhan 25 years of age with those 35 yearsld and older.Large differences in live birth rate be-
ween the pre-HAART and HAART era
TABLE 2Multivariate analysis of live birth rwomen in the pre-HAART and HAA
Pre-
HIV�
Age†
..........................................................................................................
Less than 25 121...........................................................................................................
25-29 109...........................................................................................................
30-34 118...........................................................................................................
35� (ref) 94....................................................................................................................
Race/ethnicity..........................................................................................................
White (ref) 62...........................................................................................................
Hispanic 117...........................................................................................................
Black 104...........................................................................................................
Other 108....................................................................................................................
Education completed..........................................................................................................
Less than high school 128...........................................................................................................
High school 110...........................................................................................................
More than high school (ref) 61....................................................................................................................
Exposure category..........................................................................................................
Injection drug use 90...........................................................................................................
Heterosexual 92...........................................................................................................
Unknown (ref) 111....................................................................................................................
Depression (CES-D)..........................................................................................................
Less than 16 (ref) 102...........................................................................................................
16 or greater 100....................................................................................................................
Total 101....................................................................................................................† Age at time of HIV diagnosis or age at study enrollment fo
* P value represents significance level for interaction term of
ccurred among HIV-infected women H
41.e4 American Journal of Obstetrics & Gynecol
ith more than a high school –level ed-cation. Among these most highly edu-ated women, in the pre-HAART era, theirth rate among HIV-infected womenas about half that of HIV-uninfectedomen, whereas in the HAART era, the
ate among HIV-infected women wasore than double that of HIV-unin-
ected women. Whereas an increase inive birth rates in HIV-infected womenccurred across all education levels,here was a differential rate of changever time when comparing those with
ess than high school education withhose with more than a high school edu-ation (P � .05).
Women with a history of injectionrug use were the only group in both the
per 1000 person-years among HIVera cohorts and percent change
RT cohort HAART-era cohort
HIV� HIV� HIV�
.........................................................................................................................
111.9 94.4 189.4.........................................................................................................................
58.4 119.7 148.9.........................................................................................................................
47.2 99.6 97.5.........................................................................................................................
21.8 110.2 88.6.........................................................................................................................
.........................................................................................................................
26.5 51.5 95.9.........................................................................................................................
74.2 124.0 170.6.........................................................................................................................
62.9 112.5 128.5.........................................................................................................................
52.5 52.0 191.5.........................................................................................................................
.........................................................................................................................
89.6 147.3 157.5.........................................................................................................................
46.4 113.1 135.9.........................................................................................................................
33.4 62.1 129.0.........................................................................................................................
.........................................................................................................................
40.6 78.8 33.1.........................................................................................................................
50.3 108.4 132.6.........................................................................................................................
88.8 114.8 173.4.........................................................................................................................
.........................................................................................................................
49.9 94.8 162.4.........................................................................................................................
62.0 122.3 114.5.........................................................................................................................
57.0 106.7 142.5.........................................................................................................................
-uninfected women.
change in live birth rate for pre-HAART and HAART-era cohorts
IV-infected and HIV-uninfected co- b
ogy JUNE 2007
orts who experienced a decline in birthates between the 2 treatment eras. Al-hough the rates among HIV-infectedomen with heterosexual exposure risk
nd those with no identified exposureisk were higher in the HAART era, theirth rate among women with a historyf injection drug use was 19% lower. Ta-le 3 shows the age-adjusted effect ofD4 count on the live birth rate for HIV-
nfected women in the pre-HAART andAART era cohorts. In the pre-HAART
ohort, higher CD4-positive counts weressociated with higher live birth rates, yetn the HAART era, the relationship be-ween CD4-positive count and birth rateas nonlinear. Within each category ofD4-positive lymphocyte count, the
ronegative and seropositive
Percent changeP valueinteraction*HIV� HIV�
..................................................................................................................
�22 69 .02..................................................................................................................
9 155 .13..................................................................................................................
�16 106 .15..................................................................................................................
17 306 —..................................................................................................................
..................................................................................................................
�8 36 —..................................................................................................................
6 130 .41..................................................................................................................
8 104 .39..................................................................................................................
�75 246 .86..................................................................................................................
..................................................................................................................
15 76 .05..................................................................................................................
2 193 .65..................................................................................................................
1 286 —..................................................................................................................
..................................................................................................................
�13 �19 .15..................................................................................................................
18 164 .53..................................................................................................................
3 95 —..................................................................................................................
..................................................................................................................
�7 225 —..................................................................................................................
21 85 .20..................................................................................................................
5 150 .001..................................................................................................................
HIV serostatus, using Poisson regression analysis.
ate -seRT
HAA
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4......... .........
2......... .........
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2......... .........
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0......... .........
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r HIV
irth rate was higher in the HAART era,
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www.AJOG.org Obstetrics Research
nd the greatest differences in liveirth rate were observed in the lowestD4 category. CD4 count was not in-
luded in the final Poisson regressionodel, which included HIV-unin-
ected controls.
OMMENTn a study of HIV-infected and at-riskomen recruited before and afterAART became available in the United
tates, we found that live birth rates wereignificantly higher in the latter periodmong HIV-infected women, even afterdjusting for several potential con-ounders. These findings suggest that thevailability of effective interventions forhe treatment of HIV infection and in-erruption of maternal to child transmis-ion has markedly influenced the repro-uctive choices of HIV-infected women
n the United States.Effective therapies have markedly im-
roved the prognosis for HIV-infectedomen and their infected children, and
eductions in the mother-to-child-ransmission rate to as low as 1-2% areow achievable.4,5 Studies conductedarlier in the HIV epidemic found thator women living with HIV, serostatus isot the primary influence on pregnancy-elated decisions.8,9,13-15 In several stud-es, although women expressed concernsbout the risk of perinatal transmissionf HIV, the strongest influence on theecision to carry a pregnancy to term washe woman’s desire for a child.8,9,16 Yethanging trends in pregnancy outcomesmong HIV-infected women have beeneported in Europe; in 1987 the abortionercentage exceeded that of delivery
TABLE 3Live birth rates according to CD4women in the pre-HAART and HAACD4 count atstudyenrollment
Pre-HAART cohortLive births/1000person-years
Less than 200 42.4...................................................................................................................
200-350 53.6...................................................................................................................
More than 350 70.2...................................................................................................................
* Adjusted for age at diagnosis in a Poisson regression mod
27% delivery vs 70% termination), but i
y 1996 there was a 67% delivery rate and 32% termination rate.17
In a longitudinal analysis in the U.S.dult Spectrum of HIV Disease Project,
he pregnancy rate in women with HIVas higher in the era of widespreadAART use (1997-2001), comparedith the pregnancy rate between 1992
nd 1996,18 although in that study, thereas no comparison group of HIV-unin-
ected women. Similarly, among a Euro-ean cohort of HIV-infected women
dentified during pregnancy, an increas-ng number of live births subsequent tohe index pregnancy in recent years wasound, and this time-related trend waseen in both black and white women,eading the authors to postulate that allomen in the study are likely to be influ-
nced by the availability of HAART.19
Our data extend this existing literaturey investigating the reproductive behav-
ors of both HIV-infected and at-riskomen and by including women whoere not diagnosed with HIV infection
s part of antenatal testing as well ashose who had no prior pregnancies. Pat-erns of live births for HIV-infectedomen in the United States have drasti-
ally changed across treatment eras, andn fact live births reflect an underestima-ion of the number of pregnancies occur-ing in HIV-infected women after the di-gnosis of infection. Additionally, therend of increasing live births was mostotable among older and more highlyducated HIV-infected women, suggest-ng that awareness of the beneficial ef-ects of HAART had greater influence inhese subsets of women. Numerousther factors may have led to the increase
nt at enrollment for HIV-infectedera cohorts
HAART-era cohortLive births/1000person-years P value*
198.5 .03..................................................................................................................
123.9 .62..................................................................................................................
142.6 Ref..................................................................................................................
n live births we observed in HIV-in- a
JUNE 2007 America
ected women. Public perception of HIVas changed considerably over time,uch that it is now considered a chronic,lthough incurable illness. Progress haseen made not only in treatment of HIV
nfection but also in antidiscriminationnitiatives, which may have contributedo a greater willingness of HIV-infectedomen to carry their pregnancies to
erm.One limitation of our study was that
D4 count and HIV viral load levelsere not available at the time of theirths, which occurred prior to study en-ollment. It is possible that birth ratesere higher for HIV-infected women in
he HAART era because these womenere healthier. However, in a separate
nalysis of HIV-infected women, thehange in live births between the pre-AART and HAART eras was actually
ignificantly greater for the women in theowest category of CD4 count, even afterdjustment for age at the time of diagno-is; thus, the inclusion of CD4-positiveount would have likely strengthenedur findings.Also, we cannot distinguish betweenomen who became pregnant by choice
nd those whose pregnancies were un-anted. However, live birth rates reflect
n active decision on the part of the preg-ant woman to continue pregnancy to
erm, which we have shown is clearly as-ociated with the availability of HAART.inally, we did not specifically look atAART as an independent variable be-
ause the purpose of this study was tovaluate the population effects of thevailability of HAART on the reproduc-ive decisions of HIV-infected and at-isk women.
In conclusion, there has been a dra-atic increase in live birth rates for HIV-
nfected women since HAART becameidely available. Whereas the nature ofregnancy decision making in HIV-in-
ected women is complex, the availabilityf effective interventions to preventother-to-child transmission and im-
rove the prognosis of HIV-infected in-ividuals has shown a significant influ-nce on the reproductive decisions ofIV-infected women, favoring continu-
couRT
.........
.........
.........
tion of pregnancy. f
n Journal of Obstetrics & Gynecology 541.e5
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5
CKNOWLEDGMENTSata in this manuscript were collected by theIHS Collaborative Study Group with centers
principal Investigators) at New York City/Bronxonsortium (Kathryn Anastos); Brooklyn, NY
Howard Minkoff); Washington, DC, Metropoli-an Consortium (Mary Young); The Connie
ofsy Study Consortium of Northern CaliforniaRuth Greenblatt); Los Angeles County/South-rn California Consortium (Alexandra Levine);hicago Consortium (Mardge Cohen); Dataoordinating Center (Stephen Gange). TheIHS is funded by the National Institute of Al-
ergy and Infectious Diseases with supplemen-al funding from the National Cancer Institute,he National Institute on Drug Abuse (UO1-AI-5004, UO1-AI-31834, UO1-AI-34994, UO1-I-34989, UO1-AI-34993, and UO1-AI-42590).unding is also provided by the National Insti-ute of Child Health and Human DevelopmentUO1-HD-32632) and the National Center foresearch Resources (MO1-RR-00071, MO1-R-00079, and MO1-RR-00083).
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