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Pregnant women with COVID-19 had worse outcomes across the board, especially if the mother-to-be was also co-infected with HIV, according to a study from Botswana.

Adverse birth outcomes, such as premature delivery and stillbirth, were observed in 31% of women who tested positive for COVID-19 compared with 26% of women who did not (adjusted RR 1.31, 95% CI 1.16-1.48), reported Maya Jackson-Gibson, a fourth-year medical student at Northwestern University in Chicago, during the virtual Conference on Retroviruses and Opportunistic Infections.

Among women with both COVID and HIV, 43% experienced adverse birth outcomes compared with 30% of those who had HIV but not COVID (adjusted RR 1.78, 95% CI 1.47-2.16).

"This is the most robust data we have seen about the birth outcomes to women living with HIV and COVID-19 during pregnancy," said press conference moderator Elaine Abrams, MD, of Columbia University Irving Medical Center in New York City.

"There is a higher rate of adverse birth outcomes in women living with HIV compared to HIV-negative women. The combination of COVID-19 and HIV only makes things worse," she added. "The bottom line for the U.S. pandemic is that pregnant women should be vaccinated -- it is good for their health and good for their babies -- and that means all pregnant women, including those with HIV."

In the study, the rate of preterm delivery was 60% higher and the rate of very preterm delivery was 40% higher in those who were HIV-free and tested positive for COVID. Rates of neonatal death and small-for-gestational age did not differ significantly between infants born to COVID-positive and -negative women.

The rate of stillbirth was 5.6% for those who were COVID-positive versus 2.7% for the women who were negative (adjusted RR 1.97, 95% CI 1.37-2.84).

Women with HIV and COVID-19 had double the risk of preterm delivery or very preterm delivery and a 65% higher risk of having a baby who was small-for-gestational age. COVID-19 positivity did not affect the risk of stillbirth or neonatal death.

For their study, Jackson-Gibson and colleagues used data from the Tsepamo Study, a birth outcomes surveillance system that captures the effects of HIV and antiretroviral treatment across government hospitals throughout Botswana.

Botswana has a high prevalence of women living with HIV and experienced a severe nationwide COVID-19 outbreak in 2021, Jackson-Gibson said.

The researchers evaluated adverse birth outcomes among women at 13 Tsepamo sites from Sept. 1, 2020 to Sept. 30, 2021 "during a period when few women had access to COVID-19 vaccination." During the study period, vaccine receipt in Botswana was limited to less than 15% of the total population by the end of 2021.

Women were included in the study if they had a known HIV status, had a singleton birth, and had undergone COVID-19 screening with rapid antigen or PCR testing 14 days prior to delivery and up to 3 days after delivery.

During the study period, 11,483 women were tested for COVID-19, with 4.7% testing positive; of these women, 144 were living with HIV. Women with HIV were significantly more likely to test positive for COVID-19 at delivery (5.6% vs 4.3%, P<0.01). Those who tested positive for COVID-19 were slightly older and more likely to deliver at a referral hospital. Four percent of women who tested positive died.

"Further research is warranted to understand the biological interaction between COVID-19, HIV infection, and adverse birth outcomes, and whether some associations were impacted by challenges in care delivery during the height of the COVID-19 epidemic in Botswana," Jackson-Gibson said.

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