Validation of the International Guide for Monitoring Child Development demonstrates good sensitivity and specificity in four diverse countries.

AIM: It is of critical importance to have internationally constructed tools to address early childhood development. The aim of this second phase of a two-phase study was to examine the sensitivity and specificity of the Guide for Monitoring Child Development (GMCD) in identifying developmental delay in four diverse countries. METHODS: The first phase of this 2011-2015 back-to-back study included 4949 children up to 42 months of age from primary healthcare centres in Argentina, India, South Africa and Turkey. Distribution curves were generated to show the ages when the children attained GMCD milestones and those that could be used across sexes and countries were placed in age ranges corresponding to the 85th and 97th percentile point estimates. Phase two examined a separately recruited sample of children in those countries to determine sensitivity and specificity of the GMCD. RESULTS: The validation phase of the 85 milestones in the GMCD identified delayed development in 30% of the 1731 children in the four countries. The sensitivity and specificity ranged from 0.71-0.94 and 0.69-0.82, respectively, for the total sample and the different age groups. CONCLUSION: The GMCD standardised in four diverse countries has appropriate accuracy for identification of children with developmental delay.

Video Game Intervention for Sexual Risk Reduction in Minority Adolescents: Randomized Controlled Trial.

BACKGROUND: Human immunodeficiency virus (HIV) disproportionately impacts minority youth. Interventions to decrease HIV sexual risk are needed. OBJECTIVE: We hypothesized that an engaging theory-based digital health intervention in the form of an interactive video game would improve sexual health outcomes in adolescents. METHODS: Participants aged 11 to 14 years from 12 community afterschool, school, and summer programs were randomized 1:1 to play up to 16 hours of an experimental video game or control video games over 6 weeks. Assessments were conducted at 6 weeks and at 3, 6, and 12 months. Primary outcome was delay of initiation of vaginal/anal intercourse. Secondary outcomes included sexual health attitudes, knowledge, and intentions. We examined outcomes by gender and age. RESULTS: A total of 333 participants were randomized to play the intervention (n=166) or control games (n=167): 295 (88.6%) were racial/ethnic minorities, 177 (53.2%) were boys, and the mean age was 12.9 (1.1) years. At 12 months, for the 258 (84.6%) participants with available data, 94.6% (122/129) in the intervention group versus 95.4% (123/129) in the control group delayed initiation of intercourse (relative risk=0.99, 95% CI 0.94-1.05, P=.77). Over 12 months, the intervention group demonstrated improved sexual health attitudes overall compared to the control group (least squares means [LS means] difference 0.37, 95% CI 0.01-0.72, P=.04). This improvement was observed in boys (LS means difference 0.67, P=.008), but not girls (LS means difference 0.06, P=.81), and in younger (LS means difference 0.71, P=.005), but not older participants (LS means difference 0.03, P=.92). The intervention group also demonstrated increased sexual health knowledge overall (LS means difference 1.13, 95% CI 0.64-1.61, P<.001), in girls (LS means difference 1.16, P=.001), boys (LS means difference 1.10, P=.001), younger (LS means difference 1.18, P=.001), and older (LS means difference=1.08, P=.002) participants. There were no differences in intentions to delay the initiation of intercourse between the two groups (LS means difference 0.10, P=.56). CONCLUSIONS: An interactive video game intervention improves sexual health attitudes and knowledge in minority adolescents for at least 12 months. TRIAL REGISTRATION: Clinicaltrials.gov NCT01666496; https://clinicaltrials.gov/ct2/show/NCT01666496 (Archived by WebCite at http://www.webcitation.org/6syumc9C0).

Early diagnosis is critical to ensure good outcomes in HIV-infected children: outlining barriers to care.

HIV-infected children require early initiation of antiretroviral therapy (ART) to ensure good outcomes. The aim was to investigate missed opportunities in childhood HIV diagnosis leading to delayed ART initiation. Baseline data were reviewed of all children aged <15 years referred over a 1-year period for ART initiation to the Kalafong Hospital HIV services in Gauteng, South Africa. Of the 250 children, one-quarter (24.5%) was of school-going age, 34.5% in the preschool group, 18% between 6 and 12 months old and 23% below 6 months of age (median age = 1.5 years [interquartile range 0.5-4.8]). Most children (82%) presented with advanced/severe HIV disease, particularly those aged 6-12 months (95%). Malnutrition was prominent and referrals were mostly from hospital inpatient services (61%). A structured caregiver interview was conducted in a subgroup, with detailed review of medical records and HIV results. The majority (≥89%) of the 65 interviewed caregivers reported good access to routine healthcare, except for postnatal care (26%). Maternal HIV-testing was mostly done during the second and third pregnancy trimesters (69%). Maternal non-disclosure of HIV status was common (63%) and 83% of mothers reported a lack of psychosocial support. Routine infant HIV-testing was not done in 66%, and inadequate reporting on patient-held records (Road-to-Health Cards/Booklets) occurred frequently (74%). Children with symptomatic HIV disease were not investigated at primary healthcare in 53%, and in 68% of families the siblings were not tested. One-third of children (35%) had a previous HIV diagnosis, with 77% of caregivers aware of these prior results, while 50% acknowledged failing to attend ART services despite referral. In conclusion, a clear strategy on paediatric HIV case finding, especially at primary healthcare, is vital. Multiple barriers need to be overcome in the HIV care pathway to reach high uptake of services, of which especially maternal reasons for not attending paediatric ART services need further exploration.

The role of parenting in affecting the behavior and adaptive functioning of young children of HIV-infected mothers in South Africa.

Prior investigations suggest that maternal HIV/AIDS poses significant challenges to young children. This study investigates the relationships between mothers' psychological functioning, parenting, and children's behavioral outcomes and functioning in a population of women living with HIV (N = 361) with a child between the ages of 6 and 10 years in Tshwane, South Africa. Utilizing path analysis, findings revealed that maternal depression is related to increased parenting stress and parent-child dysfunction, maternal coping is related to parenting style, and maternal coping, parenting style and stress, and parent-child dysfunction are associated with children's behavior and functioning, with parenting emerging as an important mediator. These findings suggest that interventions for women living with HIV and their children should not only address maternal psychological functioning (depression and coping), but should also focus on parenting, promoting a positive approach.

Psychosocial variables associated with coping of HIV-positive women diagnosed during pregnancy.

To identify psychosocial variables related to the use of coping strategies by HIV-positive South African women diagnosed during pregnancy, structured interviews were conducted with 224 HIV-positive women at antenatal clinics over a period of 2 years. Two coping styles, active and avoidant coping, were assessed using an adapted version of the Brief COPE. Psychosocial variables associated with changes in coping over time were identified with mixed linear analysis. Increases in active coping were associated with decreasing levels of internalized stigma and depression, increasing self-esteem and positive social support, knowing someone who is living with HIV, being physically healthy and living above the poverty line. Increases in avoidant coping were associated with increasing internalized stigma and depression, lower levels of self-esteem, HIV-knowledge and lower levels of education. Recommendations are made for psychological support services to strengthen women's ability to cope and enhance their health and that of their infants.

Where are the men? Targeting male partners in preventing mother-to-child HIV transmission.

Involvement of male partners may increase adherence to and improve outcomes of programs to prevent mother-to-child HIV transmission (PMTCT). Greater understanding of factors impeding male voluntary HIV counseling and testing (VCT) is needed. A cross-sectional study was conducted in Tshwane, South Africa. Semi-structured interviews were completed with men whose partners had recently been pregnant. Of 124 men who participated, 94% believed male HIV testing was important, but 40% had never been tested. Of those tested, 32% were tested during the pregnancy, while 37% were tested afterward. Fifty-eight percent of men reported that their female partners had disclosed their test results during pregnancy. A man's likelihood of testing during pregnancy was associated with prior discussion of testing in PMTCT, knowing the female partner had tested, and her disclosure of the test result (all p<0.05). In terms of increasing male-partner HIV testing rates, 74% of the men reported they would respond favorably to a written invitation for VCT from their partners. Based on themes that emerged during the interviews, six partner invitation cards to encourage male involvement in PMTCT were designed. Responses to the cards were elicited from 158 men and 409 women. One invitation card framed by the themes of fatherhood and the baby was selected by 41% of men and 31% of women as the most likely for women undergoing PMTCT to bring to their male partners and the most successful at encouraging men to be tested. In conclusion, this study found that a substantial proportion of men whose partners were recently pregnant had never been tested themselves; of those who had tested, most had done so only after the pregnancy. Encouraging partner communication and clinic attendance using an invitation card could facilitate increased male testing and participation in PMTCT.

The coping strategies used over a two-year period by HIV-positive women who had been diagnosed during pregnancy.

Structured interviews were conducted with 224 HIV-positive women diagnosed during pregnancy, at antenatal clinics in Tshwane, South Africa, in order to investigate the use of coping strategies during the first two years after diagnosis. Interviews were conducted between one and four weeks after diagnosis during pregnancy, with three follow-up interviews conducted post-partum. Coping strategies were assessed with an adapted version of the Brief COPE. It was found that active coping was used more often than avoidant coping throughout the study period. Active coping increased over time, while avoidant coping decreased at first but increased again between 6 and 21 months after diagnosis. The most frequently used coping strategies included acceptance, direct action, positive reframing, religion and distraction. At first, women coped through internalised strategies. Over time, outward-focused strategies developed. Avoidant coping patterns differed from previous research indicating that women diagnosed during pregnancy deal with the consequences of HIV after the baby is born. Recommendations for mental health services are made.

Behavior and psychological functioning of young children of HIV-positive mothers in South Africa.

Adults with HIV are living longer due to earlier diagnosis and increased access to antiretroviral medications. Therefore, fewer young children are being orphaned and instead, are being cared for by parents who know they are HIV positive, although they may be asymptomatic. Presently, it is unclear whether the psychological functioning of these young children is likely to be affected or, alternatively, whether it is only when a mother is ill, that children suffer adverse effects. We, thus, aimed to compare the behavior and psychological functioning of young children (aged 6-10 years) of HIV-positive and HIV-negative mothers. We also aimed to examine the association between HIV status disclosure and child outcomes. This study uses cross-sectional data from the baseline assessment of a randomized controlled trial conducted in Tshwane, South Africa. Participants (n=509) and their children were recruited from area health clinics. Among the 395 mothers with HIV, 42% reported symptoms of HIV disease. Multivariate linear regression models suggested that after adjusting for socio-demographic characteristics, children of HIV-positive mothers had significantly greater externalizing behaviors than children of HIV-negative mothers. Importantly, children whose mothers were symptomatic had greater internalizing and externalizing behaviors compared with children of HIV-negative mothers, but this was not true for children of asymptomatic mothers. Additionally, among children of HIV-positive mothers, those who had been told their mothers were sick compared with children who had been told nothing had less internalizing and externalizing behaviors and improved daily living skills. This study, therefore, provides evidence that maternal HIV disease can affect the behaviors of young children in South Africa but, importantly, only when the mothers are symptomatic from their disease. Furthermore, results suggest that disclosure of maternal illness but not HIV status was associated with improved behavior and psychological functioning among young children.

Development of a measure of the patient-provider relationship in antenatal care and its importance in PMTCT.

The prevention of mother-to-child HIV transmission (PMTCT) is a complex challenge in heavily affected and resource-limited settings such as South Africa. Management of PMTCT requires a cascade of interventions that need to be addressed to effectively decrease the risk of HIV transmission to infants. This PMTCT cascade includes incremental components that can be shaped and influenced by the patient-provider relationship. The relationship that a pregnant woman has with her care providers may possibly affect decisions that she makes concerning her antenatal care and may, in turn, influence the quality of the care provided. A patient-provider relationship scale (PPRS) was developed in Pretoria, South Africa with two aims: first, to quantify the patient-provider relationship in an antenatal population in a resource-limited setting and provide preliminary evidence of its reliability and validity; and second, to determine whether the patient-provider relationship has an effect on PMTCT. The instrument was administrated in a cross-sectional pilot study to a group of women at discharge after delivery (n=192) at two major hospitals in South West Tshwane. Statistical analysis of the instrument showed high reliability (α=0.91) and preliminary evidence of its validity including significant associations with participants' attitudes regarding the functioning of the clinics and a single statement (the clinic staff "know me as a person," R=0.47, p<0.001) that has been shown previously to have a significant association with adherence to antiretroviral treatment. For HIV-positive participants, the PPRS was significantly associated with statements related to important components of the PMTCT cascade. In addition, those with substantially inadequate antenatal care (≤2 visits) and those who did not initiate highly active antiretroviral therapy, although eligible, had significantly poorer PPRS scores. The PPRS is a potentially useful, context-appropriate instrument that could have an important role in future research focused on improving PMTCT and decreasing the risk of HIV infection in children.

The impact of structured support groups for pregnant South African women recently diagnosed HIV positive.

The authors of this study evaluated a structured 10-session psychosocial support group intervention for newly HIV-diagnosed pregnant South African women. Participants were expected to display increases in HIV disclosure, self-esteem, active coping and positive social support, and decreases in depression, avoidant coping, and negative social support. Three hundred sixty-one pregnant HIV-infected women were recruited from four antenatal clinics in Tshwane townships from April 2005 to September 2006. Using a quasi-experimental design, assessments were conducted at baseline and two and eight months post-intervention. A series of random effects regression analyses were conducted, with the three assessment points treated as a random effect of time. At both follow-ups, the rate of disclosure in the intervention group was significantly higher than that of the comparison group (p<0.001). Compared to the comparison group at the first follow-up, the intervention group displayed higher levels of active coping (t=2.68, p<0.05) and lower levels of avoidant coping (t=-2.02, p<0.05), and those who attended at least half of the intervention sessions exhibited improved self-esteem (t=2.11, p<0.05). Group interventions tailored for newly HIV positive pregnant women, implemented in resource-limited settings, may accelerate the process of adjusting to one's HIV status, but may not have sustainable benefits over time.

Perinatal encephalopathy, the syndrome of intracranial hypertension and associated diagnostic labels in the Commonwealth of Independent States: a systematic review.

BACKGROUND: The WHO reports excessive rates of ill-defined neurological diagnoses and ineffective and potentially harmful drug treatments in children in the Commonwealth of Independent States (CIS). Collectively termed perinatal encephalopathy and the syndrome of intracranial hypertension (PE-SIH), these diagnoses are important contributors to perceived childhood morbidity and disability in the CIS. A systematic compilation of information on PE-SIH is lacking. METHODS: We systematically reviewed publications between 1970 and 2020 on PE-SIH in Azerbaijani, English, Russian and Ukrainian languages and summarised information on PE-SIH. RESULTS: We identified 30 publications (70% in Russian) published 1976-2017. The diagnosis of PE-SIH was either based on unreported criteria (67% of reports), non-specific clinical features of typically developing children or those with common developmental disorders (20% of reports) or cranial ultrasound (13% of reports). The reported proportion of children with PE-SIH in the study samples ranged from 31% to 99%. There were few published studies on reassessments of children diagnosed with PE-SIH, and these did not confirm neurological disease in the majority of children. Treatments included multiple unlicenced drugs without established effectiveness and with potential unwanted effects. CONCLUSION: This review suggests that PE-SIH is a medical diagnostic label that is used in numerous children without substantive associated disease. The diagnosis and treatment of PE-SIH is a multidimensional, iatrogenic, clinical and public health problem in the CIS. With increasing use of evidence-based medicine guidelines in the region, it is hoped that PE-SIH will gradually disappear, but actions to accelerate this change are nevertheless needed.

Development of parallel scales to measure HIV-related stigma.

HIV-related stigma is a multidimensional concept which has pervasive effects on the lives of HIV-infected people as well as serious consequences for the management of HIV/AIDS. In this research three parallel stigma scales were developed to assess personal views of stigma, stigma attributed to others, and internalised stigma experienced by HIV-infected individuals. The stigma scales were administered in two samples: a community sample of 1,077 respondents and 317 HIV-infected pregnant women recruited at clinics from the same community in Tshwane (South Africa). A two-factor structure referring to moral judgment and interpersonal distancing was confirmed across scales and sample groups. The internal consistency of the scales was acceptable and evidence of validity is reported. Parallel scales to assess and compare different perspectives of stigma provide opportunities for research aimed at understanding stigma, assessing the consequences or evaluating possible interventions aimed at reducing stigma.

To tell or not to tell: South African women's disclosure of HIV status during pregnancy.

HIV-positive pregnant women often do not disclose their serostatus to their partners, family and friends, creating potential barriers to preventing sexual transmission to partners and mother-to-child transmission through breastfeeding. This research explores recently diagnosed HIV-positive pregnant women's reasons for disclosure and non-disclosure of serostatus to various members of their social networks, as well as the consequences of their disclosure. Data were collected through open-ended questions as part of a semi-structured interview with 293 recently diagnosed HIV-positive pregnant women recruited from antenatal clinics in two townships in Tshwane, South Africa. A content analysis of responses showed that women weighed fear of abandonment and discrimination against their desire to raise risk awareness and their need for support. Partners most often responded to disclosure with disbelief and shock, whereas parents frequently exhibited emotional distress, but were still supportive, as were other relatives and friends. The women subsequently experienced low levels of adverse consequences after disclosure. The results can assist healthcare providers in understanding the complexity of pregnant women's decisions to disclose to various members of their social networks and emphasize the need for continued counselling and support.

Similarities and differences in child development from birth to age 3 years by sex and across four countries: a cross-sectional, observational study.

BACKGROUND: Knowledge about typical development is of fundamental importance for understanding and promoting child health and development. We aimed to ascertain when healthy children in four culturally and linguistically different countries attain developmental milestones and to identify similarities and differences across sexes and countries. METHODS: In this cross-sectional, observational study, we recruited children aged 0-42 months and their caregivers between March 3, 2011, and May 18, 2015, at 22 health clinics in Argentina, India, South Africa, and Turkey. We obtained a healthy subsample, which excluded children with a low birthweight, perinatal complications, chronic illness, undernutrition, or anaemia, and children with missing health data. Using the Guide for Monitoring Child Development, caregivers described their child's development in seven domains: expressive and receptive language, gross and fine motor, play, relating, and self-help. Clinicians examining the children also completed a checklist about the child's health status. We used logit and probit regression models based on the lowest deviance information criterion to generate Bayesian point estimates and 95% credible intervals for the 50th percentile ages of attainment of 106 milestones. We assessed the significance of differences between sexes and countries using predefined criteria and regions of practical equivalence. FINDINGS: Of 10 246 children recruited, 4949 children (48·3%) were included in the healthy subsample. For the 106 milestones assessed, the median age of attainment was equivalent for 102 (96%) milestones across sexes and 81 (76%) milestones across the four countries. Across countries, median ages of attainment were equivalent for all play milestones, 20 (77%) of 26 expressive language milestones, ten (67%) of 15 receptive language milestones, nine (82%) of 11 fine motor milestones, 14 (88%) of 16 gross motor milestones, and eight (73%) of 11 relating milestones. However, across the four countries the median age of attainment was equivalent for only two (22%) of nine milestones in the self-help domain. INTERPRETATION: The ages of attainment of developmental milestones in healthy children, and the similarities and differences across sexes and country samples might aid the development of international tools to guide policy, service delivery, and intervention research, particularly in low-income and middle-income countries. FUNDING: Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The political path to mandatory prenatal HIV testing in Connecticut.

Editor's note: The study by Simpson and Forsyth published in this issue of JANAC is an evaluation of women's reactions to Connecticut Public Act 99-2, which established mandatory HIV testing for pregnant women in the state. Manuscript reviewers requested further information about the legislation. The authors provide an overview of the legislation in this commentary.

State-mandated HIV testing in Connecticut: personal perspectives of women found to be infected during pregnancy.

In the 5 years after the adoption of state-mandated HIV testing in Connecticut, 33% of HIV-positive pregnant women in the state were newly diagnosed during their pregnancy. Women who first learned that they were HIV-infected during pregnancy comprised of a unique group of people tested, in essence, by state mandate. A total of 11 such women agreed to in-depth interviews to share their personal perspectives regarding the benefits as well as the adverse sequelae of HIV testing for themselves, their children, and the public health. Each woman recalled her initial response to the law, to her HIV diagnosis, and to the seemingly unavoidable challenge to her self-identity and described the ensuing adjustments. There was universal agreement by the study subjects that the law was of overriding and significant benefit.

Assessment of Neurodevelopment, Nutrition, and Inflammation From Fetal Life to Adolescence in Low-Resource Settings.

Efforts to improve child neurodevelopment are critical to health, equity, and sustainable development, particularly in low-resource settings in the United States and globally. The colliding epidemics of food insecurity, infectious diseases, and noncommunicable diseases interact and impact neurodevelopment. Understanding the complex relationships between nutrition, inflammation, and neurodevelopment can inform clinical and public health interventions to improve outcomes. This article reviews key definitions, tools, and considerations for the assessment of nutrition, inflammation, and child neurodevelopment. The effectiveness of existing assessment tools to reflect status and biology, particularly in relation to each other, and to predict long-term changes in health is examined. The aim of this review is to present the extant evidence, identify critical research gaps, and suggest a research agenda for future longitudinal and intervention studies to address the assessment of nutrition, inflammation, and child neurodevelopment, particularly in low-resource settings. Despite research gaps, there is a strong relationship between nutrition, inflammation, environmental factors, and child neurodevelopment, which emphasizes the need to evaluate targeted, early interventions to improve long-term health and well-being.

The interpreter as cultural educator of residents: improving communication for Latino parents.

OBJECTIVE: To determine whether augmentation of the Spanish interpreter's role to include cultural education of residents can improve the satisfaction of Latino patients. DESIGN: We assessed parent satisfaction during 4 sequential 2-month periods between June 1, 2004, and February 11, 2005, using different interpretation methods: telephone interpretation (n = 91 patient encounters), trained in-person interpretation (n = 49), in-person interpretation with cultural education of residents (n = 65), and postprogram telephone interpretation (n = 45). SETTING: General pediatric practice at a large teaching hospital. PARTICIPANTS: A total of 250 Spanish-speaking parents who were limited in English proficiency. INTERVENTIONS: The cultural education program included 3 brief preclinic conferences taught by an interpreter and one-on-one teaching of residents about language and cultural issues after each clinical encounter. MAIN OUTCOME MEASURES: Parent satisfaction was assessed using 8 questions that have previously been validated in Spanish. Lower scores indicated more satisfaction. RESULTS: Because they were limited in English proficiency, our Spanish-speaking patients were significantly more satisfied when an in-person interpreter was used compared with a telephone interpreter (mean total satisfaction score of 14.5 [in-person] vs 17.4 [telephone]; P = .006) but were even more satisfied when the interpreter educated residents in cultural and language issues (mean, 11.5 [in-person with education] vs 17.4 [telephone]; P<.001). CONCLUSION: Although use of an in-person interpreter can increase Latino parents' satisfaction, a program using an interpreter to educate residents in cultural and language issues can increase satisfaction further.

Barriers to early prenatal care in South Africa.

OBJECTIVE: To understand the barriers delaying early prenatal care for women in South Africa. METHODS: A mixed-methods study was conducted at a center in Pretoria. RESULTS: Following interviews with 21 women at a prenatal clinic in Pretoria, a quantitative survey was completed by 204 postpartum women. During interviews, women described presenting late owing to contemplating induced abortion, fear of HIV testing, and fear of jealousy and bewitching. The survey results demonstrated that a majority of women (133 [65.2%]) reported knowledge of recommendations to present before 12weeks; however, the average gestational age at initial presentation was 19.1±7.7weeks. Women were more likely to present earlier if the pregnancy was planned (P=0.013) and were less likely to if they had at any point contemplated induced abortion (P=0.021). Fears of bewitching and harmful psychological stress owing to a positive HIV test result prevailed in both the interviews and the surveys. CONCLUSION: Significant efforts should be devoted to improving access to contraception and prepregnancy counseling in order to improve early prenatal care attendance. Similarly, addressing cultural concerns and fears regarding pregnancy is imperative in promoting early attendance.

Pregnancy and birth rates among HIV-infected women in the United States: the confounding effects of illicit drug use.

OBJECTIVE: To determine the effect of HIV infection on pregnancy and birth rates and assess the potentially confounding effect of illicit drug use. DESIGN: A retrospective record review of matched cohorts examining pregnancy outcomes for HIV-positive women and two HIV-negative comparison groups (one matched by drug use). METHODS: Ninety HIV-positive women who gave birth in a US city between 1989 and 1993 were matched to HIV-negative women by race, age, parity and date of index birth (group 1, N = 180) and also by the type of illicit drug used (group 2, N = 90). Data were abstracted on tubal ligations and pregnancies occurring before April 1996. RESULTS: A total of 63% of HIV-positive women used cocaine during the index pregnancy and 26% also used opiates. HIV-positive women had fewer tubal ligations than group 1 (38.9% versus 51.1%, P = 0.058), but there was no difference when matching included drug use (38.9% in group 2). HIV infection was associated with a decrease in the number of pregnancies; this decrease was most marked when matching included drug use (18.0 versus 32.1 pregnancies per 100 woman-years,P < 0.01). There were no significant differences in spontaneous or therapeutic terminations. Poisson regression analysis demonstrated that HIV infection and older age were associated with fewer pregnancies, and cocaine use with an increased pregnancy rate. CONCLUSION: This study confirms that HIV infection is associated with a decrease in the number of pregnancies, but also illustrates the confounding effects of illicit drug use among women in the United States.