- - - MATERNAL DEATHS AND HIV TREATMENT IN SUB-SAHARAN AFRICA

Friday, 17th of May 2013

MATERNAL DEATHS AND HIV TREATMENT IN SUB-SAHARAN AFRICA

Volume 381, Issue 9879, Pages 1699 - 1700, 18 May 2013

Original Text

In the past 30 years, reduction of maternal mortality has been a prominent focus in global public health. Improvements in womens reproductive health and antenatal and obstetric services mean that Millennium Development Goal 5 (target A of which aims to reduce maternal mortality by 75% between 1990 and 2015) has come within sight in many countries, most notably in Latin America and Asia.1 Yet across sub-Saharan Africa, maternal mortality has been an intractable problem. More than 50% of all maternal deaths occur in Africa, and the maternal mortality ratio in sub-Saharan Africa is more than double the global average.2, 3

Excess maternal mortality across Africa, and in southern and eastern Africa in particular, is widely attributed to the HIV/AIDS epidemic. Advanced HIV infection is associated with substantial increases in the risk of death, both during pregnancy and post partum, in clinical cohorts and maternal mortality audits.4 But despite being a core indicator for population health and access to health services, maternal mortality is notoriously difficult to measure.5 Maternal deaths can be underdetected in many settings. Most research is focused on facility-based deliveries with concomitant biases, and there is imprecision in the denominator of livebirths used to estimate maternal mortality ratios. Population-based approaches could overcome these limitations, but few adequate data sources are available.6 Thus, it is perhaps unsurprising that empirical data about how the HIV epidemic has affected maternal mortality in Africa are few and that results vary substantially.

In The Lancet, Basia Zaba and colleagues7 present novel population-based data for the relation between HIV and mortality during pregnancy and the post-partum period. These data come from the Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) network of demographic surveillance sites in eastern and southern Africa, and cover 138 074 women aged 15—49 years. Zaba and colleagues show that the excess mortality attributable to HIV infection is substantially lower during pregnancy and the post-partum period than that in non-pregnant women: 11·8 (95% CI 8·4—15·3) per 1000 person-years as compared with 51·8 (47·8—53·8) per 1000 person-years. Zaba and coworkers extrapolate from their results to estimate that roughly a quarter of pregnancy-related deaths in Africa are probably attributable to HIV. Their data have understandable limitations, which are fundamental to community-based research, and their analysis relies on a series of assumptions to which the findings seem robust. Despite these limitations, the insights provided are unique and important in terms of geographical scope, sample size, and, perhaps most importantly, the use of population-based surveillance to record pregnancies and associated outcomes.

Much of Zaba and colleagues work is focused on description of the overall association between HIV infection and maternal mortality at a population level. However, it also provides evidence for interventions to mitigate the effects of HIV on maternal mortality. Appreciable reductions in mortality in HIV-infected pregnant or post-partum women were noted after the introduction of antiretroviral therapy (ART) compared with the pre-ART era. This decrease is proportionally smaller than the substantial reductions noted in mortality in non-pregnant HIV-infected women in the ART era, but such differences are unsurprising in view of the diverse causes of maternal mortality that are not directly related to HIV infection. Irrespective of this, the importance of appreciable reductions in pregnancy-related mortality in HIV-infected women after the introduction of ART should not be understated.

Many policy makers and researchers do not view ART as an intervention to improve obstetric outcomes. This dissociation is symptomatic of a larger and detrimental separation of maternal and child health concerns from many vertically oriented HIV/AIDS policies and programmes.8 However, increasing coverage of ART is an important strategy to reduce pregnancy-related deaths at a population level in countries where the prevalence of HIV infection is high, and, in turn, potentially to help to achieve Millennium Development Goal 5 in southern Africa.9

Although ART is typically an intervention for HIV-infected individuals with advanced clinical disease and immunosuppression, the excess mortality reported in post-partum women with high CD4 cell counts suggests that universal initiation of lifelong ART in all HIV-infected pregnant women might be worth pursuing.10 Universal initiation of ART in pregnancy has been adopted already to help to reduce mother-to-child transmission of HIV and promote the health of HIV-infected mothers in several African countries. Preliminary results have been met with guarded optimism11 and recognition that the long-term implications of prescription of lifelong ART to all HIV-infected pregnant and post-partum women are poorly understood.12

In isolation, expanded coverage of ART in HIV-infected pregnant women will not reduce maternal mortality in sub-Saharan Africa. The improvements to health systems that are necessary to deliver ART could have substantial indirect benefits, including benefits for HIV-uninfected pregnant women,13 but a clear and urgent need exists for comprehensive antenatal, obstetric, and post-partum services to address the other major causes of maternal death. Nonetheless, these data from the ALPHA network provide another piece of the puzzle.

I declare that I have no conflicts of interest.

References

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11 Centers for Disease Control and Prevention. Impact of an innovative approach to prevent mother-to-child transmission of HIV—Malawi, July 2011—September 2012. MMWR Morb Mortal Wkly Rep 2013; 62: 148-151. PubMed

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a School of Public Health and Family Medicine, University of Cape Town, Observatory 7925, Cape Town, South Africa