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Background: The objective of this study was to estimate the prevalence, incidence and risk factors for pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya. Methods: The Academic Model Providing Access to Healthcare (AMPATH) program is a partnership between Moi University, Moi Teaching and Referral Hospital and a consortium of 11 North American academic institutions. AMPATH currently provides care to 85,000 HIV-positive individuals in western Kenya. Included in this analysis were adolescents aged 10–19 enrolled in AMPATH between January 2005 and February 2017. Socio-demographic, behavioural, and clinical data at baseline and time-updated antiretroviral treatment (ART) data were extracted from the electronic medical records and summarized using descriptive statistics. Follow up time was defined as time of inclusion in the cohort until the date of first pregnancy or age 20, loss to follow up, death, or administrative censoring. Adolescent pregnancy rates and associated risk factors were determined. Results: There were 8565 adolescents eligible for analysis. Median age at enrolment in HIV care was 14.0 years. Only 17.7% had electricity at home and 14.4% had piped water, both indicators of a high level of poverty. 12.9% (1104) were pregnant at study inclusion. Of those not pregnant at enrolment, 5.6% (448) became pregnant at least once during follow-up. Another 1.0% (78) were pregnant at inclusion and became pregnant again during follow-up. The overall pregnancy incidence rate was 21.9 per 1000 woman years or 55.8 pregnancies per 1000 women. Between 2005 and 2017, pregnancy rates have decreased. Adolescents who became pregnant in follow-up were more likely to be older, to be married or living with a partner and to have at least one child already and less likely to be using family planning. Conclusions: A considerable number of these HIV-positive adolescents presented at enrolment into HIV care as pregnant and many became pregnant as adolescents during follow-up. Pregnancy rates remain high but have decreased from 2005 to 2017. Adolescent-focused sexual and reproductive health and ante/postnatal care programs may have the potential to improve maternal and neonatal outcomes as well as further decrease pregnancy rates in this high-risk group.
The Academic Model Providing Access to Healthcare (AMPATH) program is a partnership between Moi University and Moi Teaching and Referral Hospital in Eldoret, Kenya and a consortium of 11 North American Academic Institutions. AMPATH works within the public health care system in Kenya and currently provides care to 85,000 HIV-positive individuals in the western part of the country. This study took place in the following counties: Bungoma, Busia, Elgeyo-Marakwet, Kisumu, Nandi, Trans-Nzoia, Uasin Gishu, and West Pokot. AMPATH is involved in inpatient and outpatient clinical care, while also working on a range of population and community health initiatives. To date, the program has not formally assessed the burden and needs of its HIV-positive female adolescent population with regards to sexual health and pregnancy. This study was a retrospective cohort study of HIV-positive adolescent girls aged 10–19 enrolled in AMPATH between January 1, 2005 and February 28, 2017. Socio-demographic, behavioural, clinical and time-updated antiretroviral treatment (ART) data were extracted from the electronic medical records and summarized using descriptive statistics. In the AMPATH program, clinical data is collected on paper forms at each patient encounter by health providers. These data are then entered into an electronic database by data entry clerks. There are separate patient encounter forms for paediatric, adult and antenatal clinics and some concepts such as marital status and family planning are not included on the paediatric forms. Baseline characteristics were defined as the participant characteristics at the time of inclusion in the study cohort. For those whose enrolment in AMPATH care occurred between the ages of 10 and 19, baseline characteristics reflect characteristics at enrolment. For those who enrolled in AMPATH care prior to 10 years of age, baseline characteristics reflect characteristics at age 10, when the participant became part of the cohort. Clinical characteristics at the time of conception included CD4 cell count per mm3, WHO clinical stage, body mass index (BMI) (kg/m2), and hemoglobin (g/dL). With the exception of CD4, these variables were defined with a window of 90 days prior to and 30 days post estimated conception date among those who became pregnant or 90 days prior to the last visit date among those who did not become pregnant. CD4 was defined with a window of 180 days prior to and 30 days post estimated conception date among those who became pregnant or 180 days prior to the last visit date among those who did not become pregnant. Approximate date of conception was determined using pregnancy-related measures such as date of last menstrual period (LMP), estimated or actual date of delivery, pregnancy status at each clinic visit and gestational age. Follow up time was defined as time of inclusion in the cohort until the date of first pregnancy or age 20, loss to follow up, death, or patient’s last visit. Participants who were pregnant and remained in care after delivery were re-initiated into the study at date of delivery. While in reality a woman cannot conceive immediately following delivery, due to sometimes inaccurate delivery dates in the medical record, this strategy was chosen as the most consistent approach to re-initiation. Data analysis was done using SAS 9.4. Categorical variables such as WHO clinical stage, clinic location, disclosure status, hospitalization status, orphan status, and pregnancy status among others were summarized using frequencies and the corresponding percentages. Continuous variables were summarized using median and the corresponding inter quartile range (IQR) when they were found to violate the Gaussian assumptions. The Gaussian assumptions were assessed using Shapiro–Wilk test and histograms. Association between pregnancy status and categorical variables was assessed using Pearson’s Chi Square test. The association between pregnancy status and continuous variables was assessed using two sample Wilcoxon-ranks sum test. Kaplan–Meier survival function was used to describe the rate of pregnancy over time. Cox proportional hazards regression model was used to assess the factors associated with pregnancy. We reported the hazard ratios and the corresponding 95% confidence intervals (95% CI). For descriptive analysis, complete cases analysis was performed for every variable (i.e. we described the participants who had observed data for each specific variable). For the regression models, missing data was treated as a separate category. For example, if for WHO clinical stage some participants had missing data then there were five categories: WHO clinical stages I, II, III, IV and a “Missing Data” group. This was done to avoid losing cases of pregnancies and, thus, enhance the power of the study. Ethics approval was obtained through the Moi University School of Medicine Institutional Research Ethics Committee and the University of Toronto Health Sciences Research Ethics Board, as part of an overall approval for retrospective analysis of the AMPATH Medical Records System (AMRS) aimed at improving clinical care. Included in this ethics approval is a waiver of informed consent, due to the retrospective nature of the analysis.
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