Background:  ART in HIV-infected women may influence the biological, social, and behavioral determinants of pregnancy.

Methods:  Using a prospective cohort design, we analyzed trends and predictors of pregnancy, desire for children, and use of family planning among a cohort of 733 HIV-infected women who were enrolled in the Home Based AIDS Care (HBAC) study and initiated ART between May 2003 and June 2006 in rural Uganda. Women were counseled on HIV prevention and family planning as part of their participation in the study and were given free condoms on request. Women interested in family planning services were referred to the nearest provider because these services were not part of the HBAC study. Women answered in-depth social and behavioral questionnaires administered in their home every quarter in year 1 after initiating ART, and every 6 to 12 months thereafter. We modeled repeated measurement of a woman’s desire for children over time using generalized estimating equation extension to the logistic regression model.

Results:  We included in this analysis 711 women on ART aged 18 to 49 years. Median follow-up was 2.05 years (IQR 2.0 to 2.1). After ART initiation, 120 (16.9%) women experienced 140 pregnancies. Incidence of pregnancy increased from 3.46/100 person-years in the first quarter of ART to 11.71/100 person-years in the fourth quarter (p <0.0001). This paralleled an increase in the proportion of women reporting sexual activity in the past 3 months from 24.4% to 32.5% over 24 months of follow-up (p = 0.001). Although 93% to 97% of all women reported not wanting any more children at any time, only 14% of women used permanent or semi-permanent family planning methods and fewer than 8% used dual contraception by their second year on ART. Young age (HR 2.02, CI 1.29 to 3.16), being married or co-habiting with a partner (HR 2.43, CI 1.66 to 3.54), having a body mass index >18.5 (HR 1.09, CI 1.01 to 1.16), and not using condoms consistently in the last 3 months (HR 1.81, CI 1.03 to 3.23) were independently associated with pregnancy.

Conclusions:  In this cohort, pregnancy incidence increased with time on ART. Most pregnancies were unintended and very few women were using semi-permanent or permanent family planning methods. Patients on ART should be routinely counseled on the effects of ART in restoring health and fertility, and comprehensive family-planning services should be integrated into ART services with an emphasis on using dual methods.