Addressing HIV-related Comorbidities in Pregnant Women

In sub-Saharan African settings where HIV/AIDS is a leading cause of maternal mortality, infectious diseases like tuberculosis, malaria, pneumonia, and sepsis have largely surpassed obstetric causes as main causes of maternal mortality.  In a study by Khan et al. in KwaZulu Natal, South Africa, tuberculosis was the third leading cause of maternal mortality (14.9%) after sepsis and hypertensive disorders; 85% of tuberculosis-positive women were co-infected with HIV.  Co-infection with tuberculosis is one of the most common causes of maternal death for women with HIV/AIDS.  When tuberculosis and HIV occur simultaneously, mortality is three to seven times greater.

Pregnant women with HIV are also at increased risk of malaria as a result of the depressed immune response during pregnancy.  In fact, the best data on the effect of HIV on malaria comes from studies of pregnant women.  As a result of women’s depressed immune response during pregnancy, they are at a greater overall risk of contracting malaria than non-pregnant women.  An estimated 500,000 additional malaria infections occur in pregnant women each year as a result of the HIV epidemic.  Not only are pregnant women with HIV more likely to have a higher incidence and density of malaria parasites than uninfected pregnant women, but they also respond less favorably to prevention and treatment and face greater risk of anemia, a contributor to maternal mortality.  These women are also likely to experience greater rates of febrile illnesses and adverse birth outcomes including low birth weight, prematurity, and intrauterine growth restriction.  Comorbidities pose one of the greatest health threats to pregnant women with HIV and are one of the strongest pathways by which HIV/AIDS increases maternal morbidity and mortality.

Compared to women with HIV who live in developed countries, the poor management of comorbidities and obstetric complications at health institutions in developing countries places women with HIV at increased risk of experiencing maternal morbidity or mortality.  By offering low-quality or inappropriate care, struggling health systems in developing countries may exacerbate the poor maternal health outcomes of women with HIV, as studies in North America and Europe report far less lethal links between HIV and maternal morbidity and mortality.

In South Africa, for example, poor quality of care is one factor driving the nation’s increasing maternal mortality ratio as is the nation’s disproportionate burden of HIV/AIDS.  A report by Human Rights Watch details shocking abuses of South African pregnant women at the hands of health care workers ranging from refusal of admission and early discharge to the collection of bribes for treatment and verbal and physical abuse.  Improving quality of care and strengthening  health systems in countries like South Africa are crucial steps for managing the intersecting HIV/AIDS and maternal mortality epidemics.

This post is part of a blog series on maternal health, HIV, and AIDS. To view the entire series, click here.

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