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Prevalence of adverse birth outcomes and external birth defects among women living with HIV in Malawi

Title
Prevalence of adverse birth outcomes and external birth defects among women living with HIV in Malawi
Presenter
Joshua Smith-Sreen
Authors
G. Bello (1,2), J. Smith-Sreen * (3), D. Williamson (4), F. Taulo (5), A.N. Kabaghe (6), K. Thomson (7), M. Kagoli (2), S. Chipeta (2), R. Nyirenda (2), Y. Babaye (1), A.F. Auld (6), E. Kim (6), B. Matatiyo (8), E. Zenengeya (8), A.S. Muula (5), I. Nyasulu (9), M.F. Gomes (10), L. Chiwala (1), M. Kamzati (1), J. Mkungudza (2,1), D. Valencia (4), C. Moore (4), G. O'Malley (7), N. Wadonda-Kabondo (6)
Institutions
(1) International Training and Education Centre for Health, Lilongwe, Malawi, (2) Ministry of Health, Lilongwe, Malawi, (3) PHI/CDC Global Health Fellowship Program, Lilongwe, Malawi, (4) Centers for Disease Control and Prevention, Atlanta, Georgia, (5) Kamuzu University of Health Sciences, Blantyre, Malawi, (6) Centers for Disease Control and Prevention-Malawi, Lilongwe, Malawi, (7) The University of Washington, Seattle, United States, (8) National AIDS Commission, Lilongwe, Malawi, (9) World Health Organization, Lilongwe, Malawi, (10) World Health Organization, Geneva, Switzerland

BACKGROUND: Routine surveillance for birth outcomes is essential to monitor safety of antiretroviral therapy (ART) during pregnancy among women living with HIV (WLHIV). We examined the prevalence of adverse birth outcomes and major external birth defects (BDs) by maternal HIV and ART status in Malawi.
METHODS: Adverse birth outcomes (prematurity, low birthweight) and BDs were recorded for all live and stillbirths delivered at four Malawian hospitals from January 2016 to July 2020 and July 2021 to November 2021. BDs were confirmed by experts at the Centers for Disease Control and Prevention. Maternal characteristics were collected from interviews and health records. Pooled prevalence and crude prevalence ratios (cPRs) were calculated using maximum likelihood estimates for adverse outcomes and BDs.
RESULTS: Among 165,402 women with informative births, the median age was 24.0 years (IQR: 20.0-30.0) and 10.1% were HIV-positive. The prevalence of prematurity and low birthweight, respectively, was significantly higher for the following populations: ART naïve WLHIV (28.3%, 18.4%), WLHIV on ART (21.4%, 14.6%) and women with unknown HIV status (27.2%, 19.2%) than HIV-negative women (19.2%, 11.9%). The most prevalent BDs (excluding syndromes) were talipes equinovarus (21.4 per 10,000 births, 95% CI: 19.3, 23.8), neural tube defects (NTDs) (9.3, 95% CI: 7.8, 10.8), and hypospadias (8.2, 95% CI: 6.9, 9.7); higher prevalence of these conditions was observed among WLHIV on ART than HIV-negative women. There was a slightly higher likelihood of WLHIV on ART delivering a baby with an NTD than HIV-negative women (cPR: 1.85, 95% CI: 1.07, 2.62).


Outcome		Women living with HIV on ART
N = 16,349 (9.9%)		ART naïve women living with HIV
N = 321 (0.2%)		HIV-negative women
N = 147,399 (89.1%)		Women with unknown HIV status
N = 1,333 (0.8%)		Total
N = 165,402 (100.0%)
Premature delivery (<37 weeks)
(prevalence per 100 births)		21.4 (20.8, 22.1)28.3 (23.5, 33.6)19.2 (19.0, 19.4)27.2 (24.8, 29.6)19.5 (19.3, 19.7)
Low birthweight (<2500g)
(prevalence per 100 births)		14.6(14.0, 15.1)18.4 (14.3, 23.1)11.9 (11.8, 12.1)19.2 (17.1, 21.4)12.3 (12.1, 12.4)
Selected external birth defects under surveillance
(prevalence per 10,000 births)		60.6(49.2, 73.7)31.2 (0.8, 172.3)48.2 (44.8, 51.9)75.0 (36.0, 137.5)49.6 (46.3, 53.1)
--Neural tube defects (anencephaly, encephalocele, spina bifida)
15.9 (10.4, 23.3)0.08.6 (7.2, 10.3)0.09.3 (7.8, 10.8)
--Orofacial clefts (cleft lip with and without cleft palate)0.6 (0.01, 3.4)*0.01.1 (0.6, 1.8)0.01.0 (0.6, 1.6)
--Hypospadias11.0 (6.5, 17.4)0.0
7.9 (6.6, 9.5)7.5 (0.2, 41.7)8.2 (6.9, 9.7)
--Talipes equinovarus (clubfoot)26.9 (19.6, 36.1)31.2 (0.8, 172.3)20.5 (18.2, 22.9)52.5(21.1, 107.9)21.4 (19.3, 23.8)
--Limb reduction defects2.4 (0.7, 6.3)0.01.2 (0.7, 1.9)0.01.3 (0.8, 2.0)
--Gastroschisis and omphalocele3.1 (1.0, 7.1)0.02.5 (1.8, 3.5)0.02.5 (1.8, 3.4)

CONCLUSIONS: Higher prevalence of adverse birth outcomes and BDs was observed among HIV-positive women. Further analyses are needed to understand the impact of a COVID-related data collection pause between 2020 and 2021, and to explore risk factors of HIV and ART status by ART regimen and timing for adverse outcomes and BDs among WLHIV in Malawi.