Understanding alcohol, cannabis use in pregnancy and postpartum in people with HIV

Rates of alcohol and cannabis use increased substantially from pregnancy to the postpartum period among people with HIV, with distinct risk factor profiles for each substance, according to a retrospective cohort study published in Pregnancy.

Both alcohol and cannabis use have grown more common among reproductive-age women in the United States over the past decade, including during pregnancy. For pregnant people with HIV (PWH), substance use carries additional clinical consequences: it is associated with suboptimal antiretroviral therapy (ART) adherence and worsening HIV disease control, both of which contribute to adverse maternal and fetal outcomes. Alcohol and cannabis use can also compound the mental health conditions that disproportionately affect PWH because of stigma, trauma, stress, and chronic illness, write the study authors.

Despite the significance of this intersection, few studies have examined substance use patterns specifically during pregnancy and the postpartum period in this population.

“We hypothesized that substance use would be higher postpartum compared to use during pregnancy and that antepartum co-morbidities (e.g., mental health conditions) and pregnancy-related events (e.g., cesarean birth) would be associated with postpartum initiation or resumption of substances,” stated the authors.

How common was substance use before and after delivery?

The investigative team analyzed data from the Surveillance Monitoring for ART Toxicities (SMARTT) study, a component of the Pediatric HIV/AIDS Cohort Study (PHACS) network, which enrolled PWH at 22 US sites. The analysis included participants who completed substance use questionnaires during pregnancy and postpartum between 2007 and 2019.

Among 1765 pregnancies with alcohol data, 8% reported alcohol use during pregnancy compared with 44% postpartum. Among 1772 pregnancies with cannabis data, 8% reported use during pregnancy vs 14% postpartum. Postpartum use patterns were categorized as never, initiation or resumption, continuation, or discontinuation, with multivariable models used to identify factors associated with postpartum initiation or resumption among those without use during pregnancy.

What factors predicted postpartum alcohol initiation or resumption?

The adjusted relative risk (aRR) of postpartum alcohol initiation or resumption was lower for each additional year of age (aRR, 0.98; 95% CI, 0.97-0.99), for those with annual household income of $10,000 or less vs. more than $30,000 (aRR, 0.77; 95% CI, 0.65-0.91), and for those with less than a high school education vs. greater (aRR, 0.84; 95% CI, 0.72-0.99).

Risk was elevated among participants from Midwest vs. Northeast locations (aRR, 1.44; 95% CI, 1.16-1.80), those with a cesarean birth (aRR, 1.14; 95% CI, 1.01-1.30), and those who used tobacco during pregnancy (aRR, 1.19; 95% CI, 1.00-1.40).

What factors predicted postpartum cannabis initiation or resumption?

Factors associated with postpartum cannabis initiation or resumption included younger age (aRR, 0.94; 95% CI, 0.91-0.97), lower household income (aRR, 1.90; 95% CI, 1.06-3.40), more recent delivery year (aRR, 1.10 per year; 95% CI, 1.02-1.18), a psychiatric diagnosis during pregnancy (aRR, 1.71; 95% CI, 1.02-2.86), and tobacco use during pregnancy (aRR, 1.94; 95% CI, 1.29-2.94).

Younger age and tobacco use during pregnancy emerged as shared risk factors across both substances, whereas psychiatric diagnosis and lower income were more specifically associated with postpartum cannabis use.

“Understanding the clinical and obstetric characteristics associated with postpartum alcohol and/or cannabis use may enhance tailoring of interventions to optimize health among postpartum people with HIV,” the authors said, adding that these findings provide a foundation for a “nuanced approach to supporting PWH with peripartum substance use.”

Reference:

Steinberg JR, Kacanek D, Broadwell, C, et al. Pregnancy and postpartum cannabis and alcohol use among people with HIV in the United States. Pregnancy. doi:10.1002/pmf2.70350