Pre-Eclampsia Rates in Women With and Without HIV in Modern ART Era in Botswana

In the era of widespread antiretroviral therapy (ART), the relationship between HIV and hypertensive disorders of pregnancy remains unclear. This study compares the prevalence, severity, and neonatal outcomes of pre-eclampsia in women living with HIV (WLWH) and women without HIV in Botswana, a country with high ART coverage.

The study was conducted at Princess Marina Hospital, Botswana's largest public tertiary referral center, where national ART guidelines support universal treatment and high rates of viral suppression among pregnant WLWH.

We analyzed data from 11,754 women delivering at Princess Marina Hospital (November 2021-December 2023), combining 2 prospective surveillance cohorts. Pre-eclampsia was defined using American College of Obstetrics (ACOG) criteria. ART use, CD4 counts, and viral load data were collected. Primary outcome was pre-eclampsia prevalence; secondary outcomes included disease severity and adverse neonatal outcomes.

Pre-eclampsia prevalence was similar among WLWH and women without HIV (8.4% vs. 8.6%). However, after adjusting for age, parity, and hypertension history, WLWH had a lower risk (adjuste risk ratio 0.84, 95% CI: 0.71 to 0.98). Neonatal outcomes among those with pre-eclampsia did not differ significantly by HIV status. Among WLWH, initiating ART preconception and achieving undetectable viral loads were associated with reduced pre-eclampsia risk.

In settings with high ART coverage, WLWH may have a lower risk of pre-eclampsia than HIV-negative peers. HIV status does not seem to affect neonatal outcomes when ART is effective. These findings support early ART initiation and sustained viral suppression to optimize maternal health.