Incident HIV among pregnant and breastfeeding women in sub-Saharan Africa: a systematic review and meta-analysis.

OBJECTIVES A previous meta-analysis reported high HIV incidence among pregnant and breastfeeding women in sub-Saharan Africa (SSA), but limited evidence of elevated risk of HIV acquisition during pregnancy or breastfeeding when compared to non-pregnant periods. The rapidly evolving HIV prevention and treatment landscape since publication of this review may have important implications for maternal HIV incidence. DESIGN Systematic review and meta-analysis. METHODS We searched four databases and abstracts from relevant conferences through December 1, 2018, for literature on maternal HIV incidence in SSA. We used random-effects meta-analysis to summarize incidence rates and ratios, and to estimate 95% prediction intervals (PI). We evaluated potential sources of heterogeneity with random-effects meta-regression. RESULTS Thirty-seven publications contributed 100,758 person-years (PY) of follow-up. The estimated average HIV incidence rate among pregnant and breastfeeding women was 3.6 per 100PY (95%PI: 1.2, 11.1), while the estimated average associations between pregnancy and risk of HIV acquisition, and breastfeeding and risk of HIV acquisition, were close to the null. Wide 95% PIs around summary estimates, however, highlighted the variability of HIV incidence across populations of pregnant and breastfeeding women in SSA. Average HIV incidence was associated with age, partner HIV status, and calendar time. Average incidence was highest among studies conducted pre-2010 (4.1/100PY, 95%PI: 1.1, 12.2) and lowest among studies conducted post-2014 (2.1/100PY, 95%PI: 0.7, 6.5). CONCLUSIONS Substantial HIV incidence among pregnant and breastfeeding women in SSA, even in the current era of combination HIV prevention and treatment, underscores the need for prevention tailored to high-risk pregnant and breastfeeding women.

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