Pregnancy, hormonal contraceptive use, and HIV-related death in Rwanda

Background: Few studies have examined the influence of pregnancy and hormonal contraception on HIV-related deaths in African women. Rwanda is a country with high fertility, high HIV prevalence, and frequent use of hormonal contraception in urban areas. Methods: Data from a prospective cohort study of 460 HIV-infected urban childbearing (18-35 years) women followed at 6-monthly intervals for 6 years in Kigali, Rwanda, were analyzed. The relationship of time-dependent measures of pregnancy and hormonal contraceptive use to death from HIV disease was assessed with multivariate models. Results: Incident pregnancy was not associated with elevated risk of death among HIV-infected women. Oral and injectable hormonal contraceptive use had borderline protective effects associated with reduced mortality (HR 0.40, 95% CI 0.15-1.07 and HR 0.48, 95% CI 0.21-1.08 for mortality, respectively) in a multivariate model including time-dependent measures. Conclusions: The results point to the benefits of integrating family planning and HIV services. In a highly pronatalist society, such as Rwanda, which is experiencing high HIV prevalence, service integration affords an opportunity to provide HIV testing to women at risk of pregnancy and to promote family planning among HIV-positive women.