Morbidity among HIV-1-infected mothers in Kenya: prevalence and correlates of illness during 2-year postpartum follow-up.

Women of reproductive age represent half of all infected HIV-1– individuals worldwide and more than half of HIV-1 infections in Africa.1 Improving maternal health has been targeted as the Fifth Millennium Development Goal, endorsed by 189 countries.2 HIV-1 infection has been shown to increase the risk of direct complications of pregnancy such as sepsis and hemorrhage. In addition, other illnesses such as tuberculosis (TB), pneumonia, and malaria are all increased significantly in pregnancy and in the postpartum period.3–6 A study conducted in Zambia found that postpartum HIV-infected women were significantly more likely to experience moderate to severe morbidity than HIV-uninfected women.7 HIV-1–infected women may initiate medical care only as a result of pregnancy, delivery, or early postpartum visits. Such encounters may present a unique opportunity to reduce morbidity and mortality in HIV-1–infected women by facilitating early HIV-1 diagnosis and providing access to HIV-1 care and treatment. HIV/AIDS seems to increase the risk of maternal mortality in Africa. Countries most severely affected by the HIV epidemic have seen marked increases in rates of maternal mortality.8,9 HIV-1 infection may be responsible for as many as 1300 excess maternal deaths per 100,000 live births.10–12 Among postpartum women in Zimbabwe, HIV-seropositive women were 10 to 30 times more likely to die from TB, pneumonia, meningitis, or sepsis than HIV-seronegative postpartum women.3 The World Health Organization (WHO) is now considering revising the definition of maternal death to include late deaths occurring up to 1 year postpartum, given accumulating evidence that increases in maternal mortality risk extend far beyond the traditionally defined 42-day post-partum period.11,13 Pregnancy results in significant immune alterations, including decreases in cell-mediated immune function, T helper cells, and natural killer cells, which may increase the risk of infection and result in more severe clinical outcomes during pregnancy and in the postpartum period.14 In a previous study conducted by our group, mortality during 2-year postpartum follow-up was 6.0% and seemed to be mainly attributable to AIDS-related illnesses, including Kaposi sarcoma, wasting syndrome, TB, cryptococcal meningitis, pneumonia, and diarrheal diseases.15 In Zimbabwe, TB, pneumonia, and meningitis accounted for two thirds of all mortality in the 24-month postpartum period.3 Although much of this mortality is directly attributable to AIDS-related illnesses, comorbidities such as diarrhea, malaria, sexually transmitted diseases (STDs), and other respiratory illnesses may occur frequently in HIV-1–infected postpartum mothers. There are limited data on prevalence or patterns of these illnesses in this population. Because many women are diagnosed with HIV-1 during pregnancy and subsequently followed in prevention of mother-to-child transmission (PMTCT) programs, it is important for maternal health as well for PMTCT program planners to quantify the burden of illness in this population and the cofactors predictive of morbidity. As part of a study evaluating postpartum maternal health among women with HIV-1, we collected data on illnesses occurring during 2-year follow-up in these women to determine the incidence of various morbidities and cofactors for the development of these illnesses.