The Incidence and Risk Factors for Pregnancy Among HIV-Positive Adolescents Enrolled in a Large HIV Treatment Program in Western Kenya from 2005-2014

Adolescent pregnancy is a major global health problem due to its association with increased maternal and neonatal mortality and morbidity, as well as its impact on a girl’s ability to pull herself and her family out of poverty. It is also a symbol of lack of control over sexual and reproductive health (SRH) decision-making. Globally, 16 million adolescent girls between the ages of 15 and 19 and 2 million under the age of 15 become pregnant each year. 95% of the world’s births to adolescents occur in developing countries. Adolescent girls with HIV represent a particularly vulnerable group, with less control over their SRH, high rates of poverty, and higher rates of vertical transmission of HIV. The aim of this study is to estimate the incidence and risk factors for pregnancy among HIV-positive adolescents enrolled in a large HIV treatment program in Western Kenya. 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 11/2005-09/2014. 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. Adolescent pregnancy rates and associated risk factors were determined using Poisson and Cox proportional hazard regression models respectively. Ethics approval was obtained through Moi University and the University of Toronto. There were 6178 adolescents eligible for analysis and followed for a total of 10599.1 person years. Median age at enrolment in HIV care was 14.6 years (IQR: 9.0 – 18.0). Only 12.3% (378/3063) had electricity at home and 13.9% (422/3047) had piped water, both indicators of the high level of poverty in this population. Of the 6178, 12.8% (n=790) were pregnant at study inclusion. 6.3% (386/6178) became pregnant at least once during follow up and 1.4% (86/6178) were pregnant at inclusion and again during follow up. These 386 incident pregnancies during follow-up translate to an incidence rate of 36.4 (95% CI: 33.0, 40.2) per 1000 woman years, or an annual birth rate of 62.5 (95% CI: 56.6, 68.8) per 1000 women. Adolescents who became pregnant in follow-up were more likely to be using ART (Adjusted Hazard Ratio, AHR: 1.67, 95% CI: 1.32, 2.11), were more likely to be older (AHR: 1.15, 95% CI: 1.06, 1.23, per year increase) and married (AHR: 1.99, 95% CI: 1.59, 2.47). A considerable number of these HIV-positive adolescents presented at enrolment into HIV care as pregnant and many become pregnant as adolescents during follow-up. The results of this analysis point to the critical need to integrate sexual and reproductive health care into HIV services for adolescent girls and women in this region. Adolescent-focused SRH and ante/postnatal care programs may have the potential to improve maternal and neonatal outcomes as well as prevent pregnancy in this high-risk group.