Volume 197, Issue 3, Supplement , Pages S123-S131, September 2007
Young, seropositive, and pregnant: epidemiologic and psychosocial perspectives on pregnant adolescents with human immunodeficiency virus infection
Article Outline
- Abstract
- Cases of Co-Occurring HIV and Pregnancy Among Adolescents
- Results
- Psychosocial and Behavioral Characteristics of HIV-Infected Pregnant Youth
- Results
- Comment
- References
- Copyright
The objective of the study was to characterize human immunodeficiency virus (HIV)-seropositive pregnant adolescents according to maternal reproductive, behavioral, and psychosocial characteristics. Data were derived from the national HIV/AIDS Reporting System (HARS, 2001-2004) and the Perinatal Guidelines Evaluation Project (PGEP, 1997-1999). Births to HIV-seropositive 13- to 21-year-olds reported to HARS via pediatric case report forms, and HIV-seropositive pregnant adolescents (aged 13- 21 years) who participated in PGEP were identified and characterized. In the 28 states with confidential, name-based perinatal HIV exposure reporting, 1183 live births occurred to 1090 seropositive adolescents. Fifteen births were to perinatally HIV-infected adolescents. HIV serostatus was known before the index pregnancy in half the cases (52.6% and 49.2% in HARS and PGEP, respectively). Of seropositive PGEP adolescents, 67% were previously pregnant; most pregnancies (83.3%) were unplanned. Many HIV-seropositive pregnant adolescents were aware of their serostatus when they became pregnant. Pregnancy and transmission risk reduction interventions targeting young seropositive females are needed.
Key words: adolescents, human immunodeficiency virus, pregnancy
The number of young people in the United States with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) has been increasing.1, 2 It is estimated that 1 of 1000, or 21,400 persons aged 18-24 years, in the United States have HIV infection.3 In 2005, based on data from 33 states with confidential name-based reporting to the Centers for Disease Control and Prevention, 1268 youth aged 13-19 years received a diagnosis of HIV infection; 5322 13- to 19-year-olds were living with HIV or AIDS. Although declining, the U.S. teen pregnancy rate is startlingly high; one third of young women in the United States (34%) become pregnant at least once before they reach the age of 20 years; 81% of these pregnancies are to unmarried teens.4 Although teen pregnancy is more prevalent than teen HIV infection, the 2 health outcomes share a number of behavioral and epidemiologic features, with similarities according to race/ethnicity, geographic region of residence, and risk behavior.
Adolescents of minority races and ethnicities are disproportionately affected by both HIV/AIDS and pregnancy. Population estimates reveal a 20-fold gap in the prevalence of HIV among non-Hispanic blacks, compared with youth of other racial and ethnic groups, and blacks account for more than half of all reported HIV infections among 18- to 24-year-olds.3, 5 In the United States in 2005, 16% of the adolescent population was black, yet 69% of reported AIDS cases in 13- to 19-year-olds were in blacks.6 Girls of minority race or ethnicity are also disproportionately affected by teen pregnancy. Pregnancy and birth rates for black and Hispanic teens are 2-3 times higher than rates for white teens. Twenty-four percent of Hispanics and 20% of non-Hispanic blacks have a birth before the age of 20 years, compared with 8% for non-Hispanic whites.7
The 2 epidemics also share geographical similarities. Perhaps not unrelated to issues of race and ethnicity, the highest concentration of teen births and a growing number of HIV infections are occurring in the southern region of the United States.8, 9 In 2003 the rate of new AIDS diagnoses for adolescents and young adults was highest in the South (22 per 100,000 population),2 and case reports suggest that the rate of AIDS may be increasing for African-American adolescents and adults in this region.10, 11
Females are exclusively at risk for pregnancy and increasingly at risk for HIV/AIDS. Girls make up a larger proportion of both AIDS cases and new HIV infections among teens than they do among adults. As with pregnancy, heterosexual contact is the mode of transmission for most adolescents with HIV,1 accounting for 63% of AIDS cases among female teens in 2001-2005.6 Unprotected intercourse is the proximal risk behavior for both pregnancy and sexually transmitted infections (STIs) including HIV. Behaviors that increase risk for pregnancy among sexually experienced girls (initiating sex before age 15 years, having 3 or more sexual partners, and failing to use contraception the first time they had sex12) are also risk factors for HIV infection among adolescent females. Contextual factors such as poverty, history of child sexual abuse, and older partner age are risk factors for teen pregnancy that also characterize females with HIV.13, 14, 15 Health risks associated with teen pregnancy (late/no prenatal care, preterm and low-birthweight-infants16, 17) have also been identified as health risks for pregnant women with HIV.18
Despite these similarities and a vast literature on adolescent sexual risk behavior and its relation to unplanned pregnancy and STIs, few studies address the combined occurrence of pregnancy and HIV. Prenatal HIV screening is a common venue for detecting HIV, but we do not know how many females have been both pregnant and HIV seropositive during their adolescent years or how many pregnancies have occurred among HIV-seropositive adolescents. Almost nothing is known about the characteristics of seropositive pregnant adolescents.
In this paper, we examine 2 data sources (the national HIV/AIDS Reporting System [HARS, 2001-2004] and the Perinatal Guidelines Evaluation Project [PGEP, 1997-1999]) to identify and characterize seropositive pregnant adolescents according to maternal (sociodemographic, health and pregnancy, behavioral, and psychosocial) and infant characteristics. Births to HIV-seropositive adolescents aged 13-21 years are reported to HARS through the pediatric case report form. We used these data to estimate cases of seropositive pregnant adolescents. Because HARS contains minimal information on maternal psychosocial and behavioral characteristics, we also conducted secondary analyses of data from PGEP, a well-characterized study of HIV-seropositive and HIV-seronegative at-risk pregnant women. By comparing seropositive adolescents with the cohort of seronegative but at-risk adolescents, as well as with seropositive adults, we were able to consider some of the unique psychosocial and behavioral characteristics of pregnant adolescents with HIV.
Cases of Co-Occurring HIV and Pregnancy Among Adolescents
Materials and methods
Using pediatric case report forms from their perinatally exposed infants, we analyzed maternal characteristics of adolescents, aged 13-21 years, delivering a live infant during 2001-2004 and reported to the Centers for Control and Prevention (CDC) through December 2005 from the 28 states (Alabama, Arizona, Arkansas, Colorado, Connecticut, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, Ohio, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming) that had conducted confidential, name-based perinatal HIV exposure reporting since at least 2001. HIV/AIDS surveillance data have been determined to be exempt from institutional review board approval.
We examined the following maternal characteristics: number of births, age, timing of HIV diagnosis, risk factors, and prenatal care. Infant characteristics included race/ethnicity, birth weight, receipt of zidovudine (ZDV), and caretaker information. Race/ethnicity was categorized into non-Hispanic white, non-Hispanic black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native.
Results
In the years 2001-2004, 1090 seropositive females aged 13-21 years (in the 28 states with confidential, name-based perinatal HIV exposure reporting) had at least 1 pregnancy, which resulted in 1183 live births (87 had 2 pregnancies, 3 had 3 pregnancies). Of the 98.7% of exposed infants whose race/ethnicity was known, 74.4% were non-Hispanic black, 14.0% were Hispanic, 11.1% were non-Hispanic white, and 0.4% were other races/ethnicities. From age 14 years to age 21 years, the number of births increased with each increasing year of maternal age: 26 births (2.2%) were to young adolescents (aged 13-15 years), 246 (20.8%) were to girls in the midadolescent years (aged 16-18 years), and 911 (77%) were to older adolescents (aged 19-21 years).
The majority of infants (622, 52.6%) were born to mothers who acquired their infection through sex with someone known to have, or be at risk for, HIV. For a large proportion of infants (491, 41.5%), the mothers’ source of infection was unknown. Fifteen cases (1.3%) occurred to mothers known to have been perinatally HIV infected. Fifty births (4.2%) occurred to mothers who acquired HIV through injection drug use, and 5 (0.4%) through blood transfusion.
Information on timing of HIV diagnosis relative to the current pregnancy was known for 97.9% of births (excluding 13 births to mothers known to be infected before delivery but exact timing was not known and 1 birth to a mother who refused HIV testing). Of these, 609 births (52.6%) were to mothers who knew their positive serostatus before the index pregnancy. Of the 549 remaining births to mothers who learned of their positive serostatus during the index pregnancy or later, 451 (82.2%) were to mothers who received an HIV diagnosis during the pregnancy. Information on receipt of prenatal care was available for 76.8% of the births; of these, prenatal care was not received in 4.7% of cases (43). Of the 99.7% of births to mothers with information on prophylaxis, 90.3% were associated with receipt of ZDV during pregnancy, labor/delivery, or both.
One quarter of the infants born to adolescent mothers (25.7%) had low birthweight (less than 2500 g); 10.1% had a birthweight of less than 1500 g. Of those with available information (94.9%), 18.3% of infants were born premature. Information on the child’s custody/caretaker was known for 84.8% of the sample; of these, 94.2% were with a biological parent at the time of the initial report. The remainder were with a foster/adoptive relative or nonrelative (2.5%), another relative (1.9%), or a social service agency (1.1%).
Psychosocial and Behavioral Characteristics of HIV-Infected Pregnant Youth
Materials and methods
From 1995 to 2000, the CDC funded the PGEP to examine, among other things, psychosocial consequences of HIV diagnosis and infection during pregnancy. Between 1996 and 1999, 634 HIV-seropositive and HIV-seronegative but at-risk pregnant women were interviewed and then followed up for 6 months after delivery. This well-characterized cohort has been the subject of multiple reports on psychosocial and behavioral aspects of HIV and pregnancy in the eras of perinatal prophylaxis and highly active antiretroviral therapy (HAART). However, no analyses ever concentrated on unique issues of youth. We conducted secondary analyses to identify the unique ways in which the seropositive adolescents differed from the seropositive adults and the at-risk but seronegative adolescents.
The cohort, design, procedures, and measures of the PGEP have been described in detail elsewhere.19 In brief, HIV-infected women were recruited from infectious disease, high-risk, or general prenatal care clinics in New York City; Connecticut; North Carolina; and Dade County, Florida. To identify characteristics unique to HIV diagnosis or illness, the seronegative comparison sample was recruited from clinics serving women with demographic and behavioral characteristics similar to the women with HIV. They were frequency matched (at a within-state level of ± 5%) to the seropositive women on HIV sexual transmission risk behavior (defined as a history of crack cocaine use, sexual intercourse with a male injection drug user (IDU), or exchange of sex for drugs or money), injection drug use, race/ethnicity, and late entry into prenatal care (20 or more weeks of gestation). Participants were interviewed at 24 weeks of gestation or later and again at 6 weeks and 6 months postpartum using a standardized assessment. Medical records of seropositive women were abstracted by trained reviewers. The study was approved by the Institutional Review Boards at the Centers for Disease Control and Prevention and each of the participating institutions.
The baseline assessment included interview questions and administration of psychosocial scales covering the following categories: demographics and socioeconomic indicators, health care factors (including timing of HIV diagnoses relative to index pregnancy), pregnancy and motherhood factors (including reproductive history and maternal-fetal attachment),20 behavioral factors (including sex and drug risk behaviors), partner factors (including partner support and abuse), and psychosocial factors (including social support,21 depression,22 social isolation,23 perceived stress,24, 25 negative life events,26 and recent experiences of violence).27 Questions regarding the baby’s caretaker and support for the mother were asked at follow-up interviews (see Ethier et al19 for a full description of measures and scales).
Results
PGEP included 147 participants 13-21 years of age; 48 (32.6%) were aged 13-18 years and 99 (67.3%) were aged 19-21 years. HIV serostatus did not differ according to age category. Of the 61 HIV-infected participants (mean age 19.8 years), 29.5% were aged 13-18 years and 70.5% were aged 19-21 years. Nearly half (49.2%) received a diagnosis of HIV before the current pregnancy. Approximately two thirds (67.2%) had been pregnant before, and more than half (52.5%) had previously given birth. Compared with younger seropositive adolescents (aged 13-18 years), older seropositive adolescents (aged 19-21 years) were more likely to have been pregnant before (χ2 [1] = 6.01, P = .01), and, for those with a main male partner, to report that the baby’s father was their current partner (χ2 [1] = 4.60, P = .05). Most (83.3%) of the index pregnancies were unplanned; 43.3% of girls had used no pregnancy prevention.
Of girls who answered condom use questions, inconsistent use before and during pregnancy was reported by 88.7% and 77.3%, respectively. More than 15% missed 3 or more prenatal care appointments, and 29.5% had inadequate prenatal care as assessed by the Kotlechuck index.28 The Table presents a description of demographic, health, behavioral, and psychosocial characteristics of the HIV-seropositive adolescents and comparison samples. With 1 exception (older seropositive adolescents reported more stress than younger seropositive adolescents [χ2 (1) = 4.41, P = .04]), there were no other differences among adolescents with HIV according to age category.
TABLE. Demographic, health, behavioral, and psychosocial characteristics of HIV-seropositive adolescents, HIV- seropositive adults, and HIV-seronegative adolescents, PGEP, 1997-1999
| Characteristics | Group 1 HIV infected aged 13-21 y % (n) (total = 61) | Group 2 HIV infected age > 22 % (n) (total = 273) | Group 3 HIV uninfected aged 13-21 y % (n) (total = 86) | P value⁎ (1 vs 2) | P value⁎ (1 vs 3) |
|---|---|---|---|---|---|
| Demographics | |||||
 Age (mean y) | 19.8 | 30.2 | 19.3 | NA | .12† |
| Race‡ | >.17 | .06 | |||
| Black (non-Hispanic) | 78.7(48/61) | 70.0(191/273) | 64.0(55/86) | ||
| Other | 21.3(13/61) | 30.0(82/273) | 36.0(31/86) | ||
| Hispanic ethnicity‡ | 11.5(7/61) | 21.2(58/273) | 20.9(18/86) | .08 | .13 |
| Education | .04 | .86 | |||
| Less than high school | 68.4(39/57) | 53.0(132/249) | 69.8(60/86) | ||
| High school/GED or more | 31.6(18/57) | 47.0(117/249) | 30.2(26/86) | ||
| Currently attending school | 18.0(11/61) | 8.4(23/273) | 37.2(32/86) | .03 | .01 |
| Monthly income | .04 | .11 | |||
| Less than $1000 | 85.2(52/61) | 72.5(198/273) | 74.4(64/86) | ||
| $1000 or more | 14.8(9/61) | 27.5(75/273) | 25.6(22/86) | ||
| Number of times moved in the prior year | .16 | .86 | |||
| 0 | 41.0(25/60) | 49.8(134/269) | 37.2(32/86) | ||
| 1 | 23.0(14/60) | 27.1(73/269) | 25.6(22/86) | ||
| 2 or more times | 34.4(21/60) | 23.0(62/269) | 37.2(32/86) | ||
| Received public assistance | 39.3(24/61) | 44.4(122/273) | 25.6(22/86) | .45 | .08 |
| Received Medicaid | 93.4(57/61) | 84.2(230/273) | 93.0(80/86) | .06 | 1.00 |
| Pregnancy characteristics | |||||
| Previous pregnancies | <.01 | .01 | |||
| 0 | 32.8(20/61) | 8.4(23/273) | 54.7(47/86) | ||
| 1 or more | 67.2(41/61) | 91.6(250/273) | 45.3(39/86) | ||
| Previous live births | <.01 | <.01 | |||
| 0 | 47.5(29/61) | 22.0(60/273) | 74.4(64/86) | ||
| 1 or more | 52.5(32/61) | 78.0(213/273) | 25.6(22/86) | ||
| Inadequate prenatal care§ | 29.5(18/61) | 26.4(72/273) | 33.7(29/86) | .62 | .59 |
| Missed 3+ prenatal care visits | 15.3(9/59) | 10.7(29/271) | 11.6(10/85) | .32 | .54 |
| Pregnancy planning | .94 | .18 | |||
| Planned | 16.7(10/60) | 18.3(49/268) | 15.1(13/86) | ||
| Unplanned, not prevented | 43.3(26/60) | 43.7(117/268) | 58.1(50/86) | ||
| Unplanned, failed prevention | 40.0(24/60) | 38.1(102/268) | 26.7(23/86) | ||
| HIV diagnosed before pregnancy | 49.2(30/61) | 59.6(110/272) | NA | .21 | NA |
| Risk behaviors | |||||
| Cigarette smoking | |||||
| Ever | 34.4(21/61) | 56.4(154/273) | 41.9(36/86) | <.01 | .36 |
| During current pregnancy | 16.4(10/61) | 31.9(87/273) | 17.4(15/86) | .02 | .87 |
| Alcohol use | |||||
| Ever | 39.3(24/61) | 58.2(159/273) | 60.5(52/86) | <.01 | .01 |
| During current pregnancy | 8.3(5/60) | 17.6(47/267) | 9.6(8/83) | .08 | .79 |
| Marijuana use | |||||
| Ever | 29.5(18/61) | 45.1(123/273) | 40.7(35/86) | .03 | .16 |
| During current pregnancy | 1.6(1/61) | 7.3(19/259) | 8.5(7/82) | .14 | .14 |
| Crack/cocaine, ever | 13.1(8/61) | 36.3(99/273) | 15.1(13/86) | <.01 | .73 |
| Injection drugs, ever‡ | 3.3(2/61) | 7.0(19/273) | 1.2(1/86) | .28 | .57 |
| Used any drug, current pregnancy | 8.2(5/61) | 17.6(48/273) | 12.8(11/86) | .07 | .39 |
| Previous drug rehabilitation | 8.2(5/61) | 32.2(88/273) | 11.6(10/85) | <.01 | .50 |
| Any sex risk(ever used crack, had sex with IDU male, or bartered sex)‡ | 21.3(13/61) | 45.4(124/273) | 17.4(15/86) | <.01 | .56 |
| Inconsistent condom use before current pregnancy | 88.7(47/53) | 83.8(196/234) | 89.5(77/86) | .37 | .88 |
| Partner characteristics | |||||
| Main male partner | 72.1(44/61) | 78.8(215/273) | 76.7(66/86) | .26 | .53 |
| Partner is baby’s father | 86.4(38/44) | 93.0(200/215) | 83.3(55/66) | .14 | .67 |
| Partner relationship length∥ | .03 | .85 | |||
| Shorter | 65.9(29/44) | 47.4(101/213) | 67.7(44/65) | ||
| Longer | 34.1(15/44) | 52.6(112/213) | 32.3(21/65) | ||
| Partner support∥ | <.01 | .04 | |||
| Low | 27.3(12/44) | 53.3(114/214) | 47.0(31/66) | ||
| High | 72.7(32/44) | 46.7(100/214) | 53.0(35/66) | ||
| Physically or emotionally abusive partner | 9.1(4/44) | 21.9(46/210) | 15.2(10/66) | .05 | .35 |
| Psychosocial characteristics | |||||
| Experienced physical or sexual violence in the last 6 mo | 6.8(4/59) | 7.4(20/270) | 8.1(7/86) | 1.00 | 1.00 |
| Social support | .95 | <.01 | |||
| Low | 86.9(53/61) | 12.8(35/273) | 90.7(78/86) | ||
| High | 13.1(8/61) | 87.2(238/273) | 9.3(8/61) | ||
| Social isolation∥ | .31 | .03 | |||
| Low | 55.9(33/59) | 48.7(130/267) | 37.2(32/86) | ||
| High | 44.1(26/59) | 51.3(137/267) | 62.8(54/86) | ||
| Depression∥ | .24 | .97 | |||
| Lower | 56.7(34/60) | 48.4(132/273) | 57.0(49/86) | ||
| Higher | 43.3(26/60) | 51.6(141/273) | 43.0(37/86) | ||
| Perceived stress∥ | .61 | .83 | |||
| Low | 55.2(32/58) | 51.5(139/270) | 57.0(49/86) | ||
| High | 44.8(26/58) | 48.5(131/270) | 43.0(37/86) | ||
| Negative life events, prior 6 mo∥ | .03 | .01 | |||
| Low | 67.2(41/61) | 51.6(141/273) | 44.2(38/86) | ||
| High | 32.8(20/61) | 48.4(132/273) | 55.8(48/86) | ||
| Maternal-fetal attachment∥ | .10 | .28 | |||
| Low | 54.7(29/53) | 42.2(97/230) | 64.0(55/86) | ||
| High | 45.3(24/53) | 57.8(133/230) | 36.0(31/86) | ||
| Outcomes¶ | |||||
| Gestational age at delivery | .71 | .54 | |||
| Less than 38 wks | 21.4(9/42) | 24.1(48/199) | 16.7(10/60) | ||
| 38 wks or longer | 78.6(33/42) | 75.9(151/199) | 83.3(50/60) | ||
| Birthweight# | .98 | .44 | |||
| Less than 2500 g | 14.3(8/56) | 14.1(37/262) | 9.7(6/62) | ||
| 2500 g or greater | 85.7(48/56) | 85.9(225/262) | 90.3(56/62) | ||
| Help with childcare at 6 wks | 91.1(41/45) | 73.1(152/208) | 87.1(54/ 62) | .01 | .52 |
| Help with child care at 6 mo | 93.0(40/43) | 84.4(162/192) | 90.7(49/54) | .14 | 1.00 |
| Baby living with you at 6 wks | 97.8(44/45) | 90.0(207/230) | 98.4(62/63) | .14 | 1.00 |
| Baby living with you at 6 mo | 97.7(42/43) | 90.1(191/212) | 89.7(52/58) | .14 | .23 |
⁎P value for comparisons are based on χ2 analyses or Fisher’s exact tests to determine significant differences between groups. |
†P value based on an independent samples t test. |
‡Variables used as matching characteristics in the overall PGEP study sample. |
∥Scores were dichotomized based on a median split using data from the entire PGEP study sample. |
¶Includes first baby only for any multiple births. |
#Low birthweight was calculated by using the procedure previously reported by Ickovics et al.18 Specifically, chart review data were used when available, otherwise, mothers’ reports were used. Ickovics et al18 previously reported a 0.98 correlation between the 2 indices. |
HIV-seropositive adolescents differed from HIV-seropositive adults in predictable ways. They had lower income, were somewhat more likely to be Medicaid recipients, had less education, and were more likely to be currently in school. The proportion of women who were Hispanic was somewhat smaller for the adolescent group than the adult group. The adolescents were less likely to have ever engaged in known HIV sexual transmission risk behavior (ever used crack, traded sex for money or drugs, or had sex with a male IDU) or to have had a previous pregnancy or birth. The adolescents were less likely to have ever used tobacco, alcohol, marijuana, or crack/cocaine, or to have been in a drug rehabilitation program. In addition, they were also less likely to be current cigarette smokers and were somewhat less likely to have used alcohol or drugs during the current pregnancy. Although the length of relationship with their male partner was shorter than that of their adult peers (we did not adjust scores for age), HIV-seropositive adolescents reported their partners to be more supportive and less abusive than partners of HIV-seropositive adults. Adolescents reported fewer recent negative life events and 6 weeks after the birth of their child they were more likely than the adults to have help with child care.
The HIV-seropositive adolescents were similar to the seronegative at-risk adolescents with respect to sociodemographics. Although matched in the full cohort according to race and ethnicity, a somewhat larger proportion of the HIV-seropositive than seronegative adolescents were black. However, the 2 samples did not differ significantly according to Hispanic ethnicity and also did not differ with respect to age, income, work status, household stability, or completion of high school/general education degree. However, compared with the seronegative sample, adolescents with HIV were significantly less likely to still be in school and somewhat more likely to be receiving public assistance. Although the 2 cohorts did not differ according to pregnancy planning or inconsistent condom use before or during this pregnancy, HIV-seropositive adolescents were more likely to have previously been pregnant and to have given birth than the seronegative adolescents. Again, the 2 (full) cohorts were matched according to history of injection drug use and the HIV sexual transmission risk behaviors of either using crack cocaine, trading sex for drugs or money, or having sex with a male IDU. Not surprisingly, the groups didn’t differ on these behaviors.
With the exception of alcohol use (HIV-seropositive adolescents were less likely to have ever used alcohol), there were no differences in any of the other drug use or sex risk behaviors assessed. Although there were no differences in partner characteristics, HIV-seropositive adolescents reported more partner support; they also reported more social support in general, less social isolation, and fewer negative life events, compared with seronegative adolescents. There were no differences in infant birthweight or gestational age at delivery.
Comment
Pregnancy is not uncommon among adolescents with HIV, particularly among older adolescents (aged 19-21 years) who accounted for approximately three quarters of the participants in these samples. During 2001-2004, we identified 1183 births to seropositive adolescents in the 28 states with confidential, name-based perinatal HIV exposure reporting. Multiple pregnancies characterized 90 adolescents. Although we cannot say whether the prior pregnancies reported by PGEP participants occurred subsequent to HIV infection, more than two thirds of the seropositive PGEP adolescents were previously pregnant, and just over half had given birth. This high prevalence of pregnancy and childbearing among HIV-seropositive youth is consistent with findings from other studies. For example, in a study of seropositive 13- to 24-year-olds participating in a psychosocial program, 42% of participants reported at least 1 pregnancy since learning their HIV status.29 Moreover, 38% of teens (13-18 years old) in the multisite Reaching for Excellence in Adolescent Care and Health (REACH) study had children at enrollment. The higher rate found for the PGEP cohort, as compared with the REACH cohort, is likely due to the inclusion of older adolescents in the PGEP cohort; indeed, one quarter of the REACH teens became pregnant in the 3 years after enrollment.30
Contrary to expectations related to younger age, seropositive adolescents were no more likely than seropositive adults to have received an HIV diagnosis as part of their current prenatal care. Across both studies, in approximately half of the births to adolescents, a diagnosis of HIV occurred before the current pregnancy (49% PGEP, 53% HARS). (Some adolescents may have tested seropositive during a previous pregnancy because more than half of the adolescents who already knew their serostatus had been pregnant before [data not shown].) Moreover, consistent with national data on teen pregnancy,4 83.3% of pregnancies in PGEP adolescents were unplanned. Although some pregnancies can be attributed to contraception failures, 43% of PGEP adolescents who did not plan their pregnancies also reported using no prevention. Taken together, these findings indicate that many HIV-seropositive adolescents who know their positive serostatus are engaging in unprotected sex and are not using any pregnancy prevention methods. The results argue strongly for risk reduction interventions specifically for young HIV-seropositive females, not only to prevent unplanned pregnancy but also to decrease HIV transmission.
Supporting published case reports documenting pregnancies among the aging cohort of perinatally infected adolescents,31, 32, 33 we found that 1.3% of infants born to adolescents during 2001 −2004 had perinatally HIV-infected mothers. In the short term, these numbers are likely to increase as surviving children enter adolescence and young adulthood.34, 35 In 1 study of 28 perinatally HIV-infected females aged 13-24 years, 10 were sexually active; 5 of the 10 had been pregnant.36 Most of the females in that study (70.8%) reported a desire to have children. However, in the largest case series to date,37 83% (15/18) of the pregnancies among perinatally HIV-infected adolescents were unintended, a proportion equivalent to that reported by the behaviorally infected adolescents in the PGEP study.
These data document the need for developmentally targeted and aggressive anticipatory guidance regarding reproduction and HIV transmission along with tested risk reduction interventions appropriate for perinatally HIV-infected adolescents. Guidance that emphasizes the often neglected issue of planning a future pregnancy would be beneficial for males with perinatally acquired HIV as well as for females. Providers caring for these youth, and those who deliver their infants, can play an important role in providing risk behavior counseling and guidance on future childbearing. The difficult struggle experienced by these teens as they attempt to balance the realities of HIV disease with their developing sexuality, normal desires to have children, and strong social pressures to have sex are illustrated by a case example reported by Levine et al.33 Of a perinatally HIV-infected teen who was an active participant in her clinic support groups, the authors write that she was “an outspoken advocate of sexual abstinence until her pregnancy was diagnosed.”
In addition to health risks, pregnant teens face unique psychosocial challenges related to education, child care, and finances. For example, teen mothers are at risk for poor educational outcomes. Of older teen mothers (aged 18-19 years), only 74% finish high school or obtain a general education degree, and only 3% complete college.38 Relative to their risk-taking but seronegative peers, the seropositive teens in PGEP had had more children, were less likely to be in school, and were more likely to be on public assistance. Although this financial assistance may be directly related to their serostatus, these adolescents will likely need extra help completing their education, locating affordable child care, and obtaining higher education and/or developing the vocational skills necessary to obtain work and achieve the financial stability necessary to support their families.
On the other hand, the seropositive adolescents felt more supported than the seronegative adolescents (in general and from their male partners) and were less lonely. It is not clear why this was the case; however, research on serostatus disclosure has suggested that many women receive unexpected support after disclosing their positive serostatus to loved ones.39 If a majority of seropositive adolescents are living with family (which could explain increased child care assistance relative to adults), they may have recently disclosed this information. Thus, these reports may reflect this increased experience of support. In addition, pregnant women with HIV are typically connected to an array of social services, including support groups, which also may have contributed to their relative lack of perceived social isolation.
To date, very little has been written specifically about pregnant adolescents with HIV. These data represent the first estimate of cases of co-occurring HIV infection and pregnancy among adolescents in the United States and some of the first information about their psychosocial and behavioral characteristics. Nevertheless, each source of information is subject to several limitations.
The national HIV/AIDS surveillance system data are subject to at least 3 limitations. First, HIV infection surveillance data from all states are not included in the national surveillance system. Although pediatric HIV infection surveillance is currently being conducted in 48 areas that use name-based HIV infection reporting, only 28 states also conduct population-based perinatal HIV exposure surveillance for infants born to HIV-seropositive mothers. Although our data are from the largest set of population-based data currently available for persons infected with HIV, the 28 states used in this analysis may not be nationally representative because they reported only 55.3% of all AIDS cases diagnosed among adolescents in the United States during 2001-2004. Second, risk behavior information about partners is limited; therefore, surveillance data cannot effectively be used to evaluate the effect of sexual behaviors on transmission of HIV infection. Last, the surveillance data do not include HIV-seropositive women who were not reported or their HIV-exposed children who tested negative or were not tested but were presumed to be negative.
The PGEP data are also subject to limitations. The study was not designed to focus on adolescents, and no attempts were made to identify representative samples of youth or to conduct matching within age groups. Because of matching criteria, the lack of differences between the 2 cohorts cannot be interpreted as a statement on the level of risk behavior in HIV-seropositive girls relative to the general population. Finally, some of these data were collected as many as 9 years ago. Although both perinatal prophylaxis to prevent mother-to-child transmission and HAART were available at that time, advances in HIV treatment and obstetric care, as well as changes in societal knowledge and attitudes about HIV, may influence the behavior and experiences of today’s seropositive pregnant youth.
Seropositive pregnant adolescents need strong pregnancy and HIV transmission prevention counseling as well as educational, vocational, and financial counseling. At the same time, these adolescents may possess certain psychosocial strengths, such as support from partners, friends, or family, that can and should be used to help them cope with the complex array of health and social demands they will face as they manage their HIV disease while parenting their newborn.
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The findings and views expressed herein are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
This work was supported in part by an appointment to the Research Participation Program at the Centers for Disease Control and Prevention, National Center for HIV, Sexually Transmitted Diseases, and Tuberculosis Prevention administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the U.S. Department of Energy and the Centers for Disease Control and Prevention. The Perinatal Guidelines Evaluation Project was originally funded through Centers for Disease Control and Prevention cooperative agreements U64/CCU412273, U64/CCU112274, U64/CCU412294, and U64/CCU212267. The study was conducted in North Carolina; Connecticut; Miami, Florida; and New York, NY.
PII: S0002-9378(07)00294-3
doi:10.1016/j.ajog.2007.03.004
© 2007 Mosby, Inc. All rights reserved.
Volume 197, Issue 3, Supplement , Pages S123-S131, September 2007
