Data from two observational cohorts (the Tsepamo Birth Outcomes Surveillance Study and Safe Birth Study) were used to investigate pre-eclampsia prevalence in women with and without HIV.  The study population included women who had a delivery or experienced a maternal death prior to delivery (minimum 24weeks gestational age) between November 2021 and December 2023 at a single tertiary referral hospital in Botswana.  The final analysis included 2,201 women with HIV and 9,553 without HIV: women with HIV were slightly older (median age 33 vs. 27 years) and had higher gravity and parity (3 vs. 2 and 2 vs. 1, respectively).  97% of women with HIV were on ART (90% were on dolutegravir) and 94% had an undetectable viral load at initial visit.  Overall, pre-eclampsia prevalence was 8.4% for women with HIV and 8.6% for women without HIV; further, although most cases (66%) had severe features, severity did not differ by HIV status.  HELLP syndrome and eclampsia rates were also similar between women with and without HIV.  After adjusting for age, parity, and hypertension history, women with HIV had a lower relative risk of pre-eclampsia compared to women without HIV (RR 0.84).  Regarding neonatal outcomes, there was no difference in risk for ELBW, VLBW, and LBW between pre-eclampsia cases based on HIV status.  There was also no increased risk of pre-eclampsia based on ART duration, recent or nadir CD4: however, women who initiated ART pre-conception and those who had an initial undetectable viral load during pregnancy had a lower risk of developing pre-eclampsia compared to women without HIV.

Although some older studies raised concern for possible increased risk of pre-eclampsia among pregnant women with HIV, there have been few contemporary studies re-examining the occurrence of pre-eclampsia and hypertensive disorders of pregnancy in women with HIV.  Findings from this observational cohort suggest that in the modern ART era of broad treatment coverage (particularly with newer INSTI-based combinations), women with HIV may actually have a lower risk of pre-eclampsia compared to women without HIV—particularly if they had started ART pre-conception and were already virologically suppressed.  Although this study was not powered to detect differences in neonatal outcomes or HIV treatment-specific factors related to pre-eclampsia development, preterm birth rates and birth weight outcomes were similar.