Adverse Maternal Outcomes Among People With Human Immunodeficiency Virus (HIV) Using Antiretroviral Therapy in Botswana

OBJECTIVE: This study aimed to evaluate maternal outcomes in a large cohort with high prevalence of human immunodeficiency virus (HIV) infection in Botswana after implementation of a treat-all policy. METHODS: In this retrospective cohort study, data were collected from the medical record at the time of discharge from November 2021 to December 2023. Outcomes were recorded in the Tsepamo Birth Outcomes Surveillance and Safe Birth studies at Princess Marina Hospital in Botswana. We evaluated maternal mortality and obstetric morbidities by HIV status, including preeclampsia, eclampsia, hemorrhage, infection, and acute pulmonary or cardiac conditions at the time of hospital discharge. RESULTS: We included 11,754 participants; 2,201 (18.7%) were pregnant people with HIV infection. Ninety-seven percent (2,135) were on antiretroviral therapy (ART) at time of delivery; 1,996 (93.5%) of those with a known ART regimen were on dolutegravir, tenofovir disoproxil fumarate, and lamivudine. Of the 1,090 people with HIV infection with known CD4 counts, 757 (69.4%) had more than 500 cells/microliter, and only 42 (3.9%) had fewer than 200 cells/microliter. Of 1,524 people with HIV infection with known viral loads, 1,436 (94.2%) were undetectable on initial testing. There were no statistically significant differences in incidence of hemorrhage (90 [4.1%] vs 370 [3.9%], adjusted risk ratio [RR] 0.93, 95% CI, 0.73–1.17), infection (38 [1.7%] vs 126 [1.3%], adjusted RR 1.56, 95% CI, 0.97–2.51), eclampsia (6 [0.3%] vs 28 [0.3%], adjusted RR 1.12, 95% CI, 0.50–2.53), acute pulmonary or cardiac conditions (15 [0.7%] vs 43 [0.4%], adjusted RR 1.22, 95% CI, 0.65–2.27), transfusion of 2 or more units of packed red blood cells (33 [36.7%] vs 110 [29.8%], P= .21), additional uterotonics (48 [53.3%] vs 173 [47.1%], P= .29), use of tranexamic acid (31 [ 34.4%] vs 106 [29.0%], P= .31), intensive care unit admission (4 [0.2%] vs 10 [0.1%], P= .31), mechanical ventilation (3 [0.1%] vs 6 [0.1%], P= .38), pressor support (2 [0.1%] vs 2 [0.0%], P= .16), or mortality (5 [0.2%] vs 11 [0.1%], adjusted RR 1.44, 95% CI, 0.46–4.57) in people with HIV infection compared with those without HIV infection. There were few notable differences, including a slightly reduced risk of preeclampsia (184 [8.4%] vs 818 [8.6%], adjusted RR 0.84, 95% CI, 0.71–0.98) and, although rare, an increased risk of uterine rupture (12 [0.5%] vs 8 [0.1%], adjusted RR 6.54, 95% CI, 2.33–18.33) in people with HIV infection compared with those without HIV infection. CONCLUSION: There was little difference in adverse maternal obstetric outcomes between people with and those without HIV infection in the treat-all era with integrase strand inhibitors (primarily dolutegravir); notable exceptions included a slightly reduced risk of preeclampsia and, although rare, an increased risk of uterine rupture in those with HIV infection.