Starting HIV treatment late in pregnancy associated with higher risk of hypertensive disorders

Starting antiretroviral therapy (ART) after the 20th week of gestation is significantly associated with an increased risk for hypertensive disorders during pregnancy, a U.S. study has found.

About This Study

“Evaluating the association of antiretroviral therapy and immune status with hypertensive disorders of pregnancy among people with HIV” was published online on May 24, 2023, in AIDS. The lead author is Lynn M. Yee, M.D., M.P.H., of the Department of Obstetrics and Gynecology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois.

Key Research Findings

This analysis of data from the Surveillance Monitoring for ART Toxicities (SMARTT) prospective cohort study assessed hypertensive disorders among 973 pregnant people living with HIV (PLWH) who enrolled between 2015 and 2019. All participants were pregnant with a single child, and none of the infants were living with HIV. Sixty-six percent of participants were Black and 27% were Latinx, with 81% of participants less than 35 years old.

Forty-four percent of participants were overweight (i.e., body mass index [BMI] was 25 to 34.9 kg/m2) and 25% of participants were obese (BMI of ≥ 35 kg/m2), and 8% of all participants had a diabetes diagnosis. Fifty percent of participants were already on ART when they became pregnant, 37% started treatment early in pregnancy, and 13% began HIV medications after 20 weeks of gestation.

Ten percent of participants had chronic hypertension and 9% newly experienced a hypertensive disorder during pregnancy. These disorders included preeclampsia, gestational hypertension, or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets).

New-onset hypertensive disorders did not differ by ART class but were more common among participants who began treatment after 20 weeks of gestation, had diabetes, or had a CD4 cell counts below 200 cells/mm3 during the first two trimesters of pregnancy. Diabetes is a common risk factor for gestational hypertension in the general population.

Discussion Highlights and Implications for Practice

Study limitations included a lack of information on hypertension during prior pregnancies, aspirin use, or confounders related to starting care late in pregnancy.

This U.S. study did not find an association between integrase inhibitor-based ART and hypertension. However, the observed association between late ART start and hypertensive disorders reiterates the need for HIV control prior to pregnancy, the authors asserted. “Access to healthcare remains vitally important to the optimization of maternal and neonatal health for many reasons, including the role of antenatal healthcare access in initiating and optimizing ART,” they wrote.

By Barbara Jungwirth