Adverse Birth Outcomes Associated with SARS-CoV-2 Infection Among Pregnant Women with and without HIV: A Longitudinal Cohort Study.

Publication date: Jul 27, 2026

COVID-19 and HIV infection are independently associated with increased risk of adverse pregnancy outcomes. However, there is limited evidence on the impact of SARS-CoV-2 infection during pregnancy in sub-Saharan Africa, particularly among women living with HIV (WLWH). Two antenatal clinics in southern Malawi (2018 – 2022). We conducted a prospective cohort study of singleton pregnancies enrolled at 20-36 weeks gestation. SARS-CoV-2 infection was determined via serologic testing at enrollment and delivery. Participants were enrolled based on HIV status and viral suppression: (1)WLWH with detectable viral load (VL), (2)WLWH with undetectable VL, and (3)HIV-negative women. We used multivariable logistic regression with adjustment for confounding to evaluate the impact of SARS-CoV-2 alone or in combination with HIV infection on the following adverse birth outcomes: low birth weight (LBW), preterm birth, small-for-gestational-age (SGA), and stillbirth or early neonatal death. Among 905 pregnant women, 29% tested positive for SARS-CoV-2, 87% of infections were mild or asymptomatic. Overall, SARS-CoV-2 infection was significantly associated with SGA births (adjusted OR [aOR]: 1. 49, 95% CI: 1. 03-2. 13) but not associated with other adverse outcomes. Among WLWH, SARS-CoV-2 was significantly associated with increased odds of LBW (aOR: 2. 07, 1. 10-3. 91) and SGA births (aOR: 1. 73, 1. 01 – 2. 91). The effect of SARS-CoV-2 infection among WLWH did not differ based on VL. SARS-CoV-2 infection during pregnancy was associated with adverse birth outcomes, particularly among WLWH. These findings underscore the need for integrated antenatal care and targeted infection prevention strategies for pregnant women with HIV in high-burden settings.

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