Fertility desires, unmet need for family planning, and unwanted pregnancies among HIV-infected women in care in Kinshasa, DR Congo.

INTRODUCTION: We assessed the fertility desires, utilization of family planning (FP) methods, and incidence of pregnancies among HIV-infected women receiving care in an HIV clinic with an onsite FP services in Kinshasa, Democratic Republic of Congo. METHODS: Between November 2011 and May 2012, all HIV-infected women who attended a routine visit at the clinic were interviewed about their fertility desires and utilization of contraceptive methods using a structured questionnaire. Routine follow-up visit data were used to identify pregnancies recorded between the interview and June 2013. RESULTS: Overall, of the 699 HIV-infected women interviewed. 249 (35.7%) reported not wanting another child. Of the 499 (72.2%) participants who were sexually active at the time of interview, 177 (35.5%) were using an effective contraceptive method, including 70 (14.0%) women who reported using condoms consistently and 104 (20.8%) who were using injectable contraception. Overall, 88 (17.6%) sexually active participants who did not want another child were not using an effective FP method, and thus are considered to have had unmet need. During the median follow-up time of 22.2 (IQR: 20.2, 23.6) months, among all women interviewed, 96 (14.1%) became newly pregnant [pregnancy rate 9.3 (95%CI: 7.6, 11.4) per 100 women-years] including 21 (8.7%) among women who initially reported not wanting another child [unwanted pregnancy rate 5.8 (95%CI: 3.6, 9.3) per 100 women-years]. CONCLUSION: The persistence of relatively high unmet need among women receiving HIV care in a clinic with onsite FP services suggests the existence of barriers that must be identified and addressed.

Quantification of CD4 responses to combined antiretroviral therapy over 5 years among HIV-infected children in Kinshasa, Democratic Republic of Congo.

BACKGROUND: The long-term effects of combined antiretroviral therapy (cART) on CD4 percentage in HIV-infected children are incompletely understood, with evidence from resource-deprived areas particularly scarce even though most children with HIV live in such settings. We sought to describe this relationship. METHODS: Observational longitudinal data from cART-naive children enrolled between December 2004 and May 2010 into an HIV care and treatment program in Kinshasa, Democratic Republic of Congo were analyzed. To estimate the effect of cART on CD4 percentage while accounting for time-dependent confounders affected by prior exposure to cART, a marginal structural linear mean model was used. RESULTS: Seven hundred ninety children were active for 2090 person-years and a median of 31 months; 619 (78%) initiated cART. At baseline, 405 children (51%) were in HIV clinical stage 3 or 4; 528 (67%) had advanced or severe immunodeficiency. Compared with no cART, the estimated absolute rise in CD4 percentage was 6.8% [95% confidence interval (CI), 4.7% to 8.9%] after 6 months of cART, 8.6% (95% CI, 7.0% to 10.2%) after 12 months, and 20.5% (95% CI, 16.1% to 24.9%) after 60 months. cART-mediated CD4 percentage gains were slowest but greatest among children with baseline CD4 percentage <15. The cumulative incidence of recovery to "not significant" World Health Organization age-specific immunodeficiency was lower if cART was started when immunodeficiency was severe rather than mild or advanced. CONCLUSIONS: cART increased CD4 percentages among HIV-infected children in a resource-deprived setting, as previously noted among children in the United States. More gradual and protracted recovery in children with lower baseline CD4 percentages supports earlier initiation of pediatric cART.

The effect of highly active antiretroviral therapy on the survival of HIV-infected children in a resource-deprived setting: a cohort study.

BACKGROUND: The effect of highly active antiretroviral therapy (HAART) on the survival of HIV-infected children has not been well quantified. Because most pediatric HIV occurs in low- and middle-income countries, our objective was to provide a first estimate of this effect among children living in a resource-deprived setting. METHODS AND FINDINGS: Observational data from HAART-naïve children enrolled into an HIV care and treatment program in Kinshasa, Democratic Republic of the Congo, between December 2004 and May 2010 were analyzed. We used marginal structural models to estimate the effect of HAART on survival while accounting for time-dependent confounders affected by exposure. At the start of follow-up, the median age of the 790 children was 5.9 y, 528 (66.8%) had advanced or severe immunodeficiency, and 405 (51.3%) were in HIV clinical stage 3 or 4. The children were observed for a median of 31.2 mo and contributed a total of 2,089.8 person-years. Eighty children (10.1%) died, 619 (78.4%) initiated HAART, six (0.8%) transferred to a different care provider, and 76 (9.6%) were lost to follow-up. The mortality rate was 3.2 deaths per 100 person-years (95% confidence interval [CI] 2.4-4.2) during receipt of HAART and 6.0 deaths per 100 person-years (95% CI 4.1-8.6) during receipt of primary HIV care only. The mortality hazard ratio comparing HAART with no HAART from a marginal structural model was 0.25 (95% CI 0.06-0.95). CONCLUSIONS: HAART reduced the hazard of mortality in HIV-infected children in Kinshasa by 75%, an estimate that is similar in magnitude but with lower precision than the reported effect of HAART on survival among children in the United States. Please see later in the article for the Editors' Summary.