HIV Infection and risk of postpartum infection, complications and mortality in rural Uganda

ABSTRACT

HIV infection may increase risk of postpartum infection and infection-related mortality. We hypothesized that postpartum infection incidence and attributable mortality in Mbarara, Uganda would be higher in HIV-infected than HIV-uninfected women. We performed a prospective cohort study of 4231 women presenting to a regional referral hospital in 2015 for delivery or postpartum care. All febrile or hypothermic women, and a subset of randomly selected normothermic women were followed during hospitalization and with 6-week postpartum phone interviews. The primary outcome was in-hospital postpartum infection. Secondary outcomes included in-hospital complications (mortality, re-operation, intensive care unit transfer, need for imaging or blood transfusion) and 6-week mortality. We performed multivariable regression analyses to estimate adjusted differences in each outcome by HIV serostatus. Mean age was 25.2 years and 481 participants (11%) were HIV-infected. Median CD4+ count was 487 (IQR 325, 696) cells/mm³, and 90% of HIV-infected women (193/215 selected for in-depth survey) were on antiretroviral therapy. Overall, 5% (205/4231) of women developed fever or hypothermia. Cumulative in-hospital postpartum infection incidence was 2.0% and did not differ by HIV status (aOR 1.4, 95% CI 0.6–3.3, P = 0.49). However, more HIV-infected women developed postpartum complications (4.4% vs. 1.2%, P = 0.001). In-hospital mortality was rare (2/1768, 0.1%), and remained so at 6 weeks (4/1526, 0.3%), without differences by HIV serostatus (P = 1.0 and 0.31, respectively). For women in rural Uganda with high rates of antiretroviral therapy coverage, HIV infection did not predict postpartum infection or mortality, but was associated with increased risk of postpartum complications.

KEYWORDS:

• HIV
• antiretroviral
• Africa
• infection
• puerperal sepsis
• pregnancy

Geolocation information

This research was performed in Mbarara, Uganda at Mbarara Regional Referral Hospital, which shares a campus with the Mbarara University of Science and Technology. The geographical coordinates are 0°36′59.0″S, 30°39′32.0″E.

Acknowledgements

The authors are grateful to the cohort participants and to the Mbarara Regional Referral Hospital Maternity Staff, Mbarara University of Science and Technology, MRRH ISS Clinic, and Epicentre Mbarara for their partnership in this research. The authors also thank Becton Dickinson (BD) for their generous donation of blood culture bottles for use in this study. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the National Institutes of Health Research Training [grant number R25 TW009337] funded by the Fogarty International Center and the National Institute of Mental Health (to LMB); National Institutes of Health T32 Ruth L. Kirschstein National Research Service Award [grant number 5T32AI007433-22] (to LMB); the Massachusetts General Hospital Center for Global Health (to LMB); Harvard University Center for AIDS Research (CFAR), an NIH funded program [grant number P30 AI060354], which is supported by Fogarty/NIMH R25 TW009337; NIH/NIAID 5T32AI007433-22; the Massachusetts General Hospital Center for Global Health; NIH P30 AI060354; NIMH K23 MH09916; the Sullivan Family Foundation; National Institutes of Health [grant number K23 MH09916] (to MJS); the Sullivan Family Foundation (to DRB); logistical support from Harvard Catalyst; and Becton, Dickinson and Company (BD) donated blood culture bottles for use in this study; National Institute of Allergy and Infectious Diseases.