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. 2025 Sep 2;25(1):924.
doi: 10.1186/s12884-025-08086-x.

Comorbidities in pregnant South African women living with HIV and associations with adverse birth outcomes: a prospective cohort study

Amohelang J Lehloa  1   2 , Emma Kalk  3 , Mary-Ann Davies  3   4 , Dorothy Nyemba  5   6 , Ushma Mehta  3 , Thokozile Malaba  5 , Gregory Petro  7 , Andrew Boulle  3   4 , Landon Myer  5 , Hlengiwe P Madlala  5
Affiliations

Comorbidities in pregnant South African women living with HIV and associations with adverse birth outcomes: a prospective cohort study

Amohelang J Lehloa et al. BMC Pregnancy Childbirth. .

Abstract

Background: Despite improved health and survival due to lifelong antiretroviral therapy (ART), women living with HIV (WHIV) still face lower life expectancy, partly due to increased non-communicable disease (NCD) risk. Both HIV and NCDs are linked to adverse birth outcomes, yet data on their combined impact are limited. We investigated NCD burden by HIV status and compared adverse birth outcomes in pregnant WHIV only versus HIV-NCD comorbidity in Cape Town, South Africa.

Methods: Pregnant WHIV (n = 479) and without HIV (n = 510) were enrolled and prospectively followed for pregnancy outcome. Weight and height measurements were serially collected by a study nurse, and diagnoses of hypertension and diabetes mellitus (DM) were made by healthcare providers as part of routine care (ANC). Birth outcomes were abstracted from health records. Proportions described adverse outcomes between groups. Logistic regression was used to estimate associations between HIV and HIV-NCD with small for gestational age (SGA), large for gestational age (LGA), preterm delivery (PTD), low birthweight (LBW), and high birthweight (HBW) (reference: group with neither HIV nor NCDs).

Results: Among 989 pregnant women, 48% (n = 479) with HIV (median age 29 years, IQR 25-34), the prevalence of obesity (BMI ≥ 30 kg/m2) was 43%, hypertension 15% and DM 2%. The NCD prevalence did not differ by HIV status. HIV co-occurred with obesity in 31% of pregnancies, with hypertension in 5% and with DM in 0.2%. HIV with hypertension and HIV with hypertension and obesity were associated with increased odds of PTD compared to those with neither HIV-NCD (aOR 3.03, 95% CI 1.01, 8.05 and aOR 2.67, 95% CI 1.08, 6.23, respectively). However, HIV and obesity together were associated with lower odds of SGA (aOR 0.39, 95% CI 0.16, 0.97). Likewise, in women without HIV, obesity protected against SGA and LBW, but hypertension increased PTD and LBW.

Conclusion: There was no difference in the prevalence of NCD in pregnant women by HIV status. Increased risk of adverse birth outcomes was demonstrated with concurrent NCD regardless of HIV status. Integration of NCD screening and management within ANC could minimise excess adverse outcomes in high HIV burden settings.

Keywords: Adverse birth outcomes; Diabetes; HIV; Hypertension; Obesity; Pregnancy.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study followed the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by relevant ethical bodies. The current study analysed data from a parent study titled B Positive. Since the study is a secondary research analysis, there was no requirement for obtaining informed consent, as participants had already consented that their information could be used for research and academic purposes. The University of Cape Town Human Research Ethics Committee had approved the parent study (HREC 541/2015) as well as the Western Cape Department of Health (REFWC_2016RP6_286). This current study sought ethical clearance from the University of Cape Town Human Research Ethics Committee (HREC 345/2022). All participants provided written informed consent prior to study participation. Consent for publication: Not applicable Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
(a) Flow diagram showing the selection of pregnant women with and without HIV (b)Flow diagram showing the selection of pregnant women with and without HIV included in the adverse birth outcomes analysis
Fig. 2
Fig. 2
Non-communicable diseases proportions by HIV status in the study (n = 989).Diabetes and hypertension were combined irrespective of chronicity due to their small proportions. Maternal morbidity is based on ever meeting the criteria for a condition at any point during the data visits i.e. obesity = pre-conception BMI ≥30 kg/m2, hypertension = systolic ≥120mmHg or diastolic ≥ 80 mmHg, Diabetes= obtained from medical records and self-reported throughout antenatal visits and checked against medical records
Fig. 3
Fig. 3
Proportions of adverse outcomes in WHIV and HIV-NCD comorbidity (n = 422). Abbreviation: NCD = Non-communicable disease, HTN = Hypertension, ANC = Antenatal care, WHIV = Women with HIV, PTD = Preterm delivery, LBW = Low birthweight, HBW = High birth weight, SGA = Small for gestational age, LGA = Large for gestational age. Maternal morbidity is based on ever meeting the criteria for a condition at any point during the data visits i.e. obesity = pre-conception BMI ≥30 kg/m2, hypertension = systolic ≥120mmHg or diastolic ≥ 80 mmHg, DM obtained from medical records and self-reported throughout antenatal visits and checked against medical records. Groups that included DM were excluded from the graphical birth outcome analyses due to very small numbers, which limited meaningful interpretation and impaired the clarity of visual presentations
Fig. 4
Fig. 4
Proportions of adverse outcomes in women without HIV with/without NCDs (n = 448). Abbreviation: NCD = Non-communicable disease, PTD = Preterm delivery, LBW = Low birthweight, HBW = High birth weight, SGA = Small for gestational age, LGA = Large for gestational age. Maternal morbidity is based on ever meeting the criteria for a condition at any point during the data visits i.e. obesity = pre-conception BMI ≥30 kg/m2, hypertension = systolic≥120mmHg or diastolic ≥ 80 mmHg, DM = obtained from medical records and self-reported throughout antenatal visits and checked against medical records. Groups that included DM were excluded from the graphical birth outcome analysis due to very small numbers, which limited meaningful interpretation and impaired the clarity of visual presentations
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