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The objective of this study is to determine the risk and cofactors for HIV acquisition during pregnancy and postpartum.A prospective cohort studyPregnant women in western Kenya were enrolled if HIV seronegative at that visit or within 3 months. Serial HIV nucleic acid amplification tests (NAATs) were conducted at 1 to 3-month intervals to 9 months postpartum. Genital swabs were collected for detection of chlamydia and gonorrhoea at baseline, and for trichomonas, bacterial vaginosis and yeast at baseline and follow-up.Among 1304 pregnant women, median age was 22 years, 78% were married for a median of 4 years, 66% reported knowing partner HIV status and 8% reported using condoms. Study retention was 98%. During 1235 person-years of follow-up, HIV incidence was 2.31/100 person-years [95% confidence interval (95% CI) 0.71–4.10]. Incident HIV was associated with syphilis (hazard ratio 9.18, 95% CI 2.15–39.3), chlamydia (hazard ratio 4.49, 95% CI 1.34–15.0), bacterial vaginosis (hazard ratio 2.91, 95% CI 1.25–6.76), yeast (hazard ratio 3.46, 95% CI 1.46–8.19), sexually transmitted infection (STI) history (hazard ratio 3.48, 95% CI 1.31–9.27), lifetime number of sex partners (hazard ratio 1.19, 95% CI 1.03–1.37), partner age discordance (hazard ratio 1.07 per year, 95% CI 1.02–1.13) and shorter marriage (hazard ratio 1.19 per year, 95% CI 1.03–1.38). No women with incident HIV reported an HIV-infected partner. In multivariate analyses, chlamydia, older partners and yeast infection remained significant; however, power was limited.Pregnant and lactating women may not perceive HIV risk and rarely used condoms. Prevention and treatment of genital infections and risk stratification to identify women for pre-exposure prophylaxis (PrEP) could decrease HIV acquisition in pregnant/lactating women.