Background
The pandemics of Human Immunodeficiency Virus (HIV) have been affecting many segments of the population all over the world [
1]. In 2016, around 36.7 million people lived with HIV [
2]. In sub-Saharan Africa and globally, 110,000 and 160,000 children got new HIV infection respectively [
2,
3].
HIV has many routes of transmission including mother-to-child transmission (MTCT) [
4]. More than 90% of children acquired HIV through MTCT [
5,
6], predominantly high in Africa [
7]. Studies reported that MTCT rate during pregnancy or postpartum period was 23% [
8] even though it varies from 15 to 45% in the absence of prophylaxis [
9]. Between 2009 and 2013, the MTCT rate reduced from 28 to 18% in sub-Saharan Africa [
10].
To control MTCT of HIV as part of end Acquired Immunodeficiency Syndrome epidemic strategy [
11,
12], several activities have been inaugurated in Ethiopia. Ethiopia implemented prevention of mother to child transmission (PMTCT) intervention since 2001 [
13], such as increasing institutional delivery, Antiretroviral coverage, infant prophylaxis, and proper feeding practices of infants [
14,
15].
However, in 2016, 40, 11, and 26% of Ethiopian women ever screened for HIV, started mixed feeding for infants before 6 months and delivered at health institutions, respectively [
16]. Consequently, MTCT of HIV occurred significantly. Similarly, there were an estimated 14,000 HIV-positive newborns in Ethiopia [
17].
Despite many efforts to study the prevalence and risk factors of MTCT of HIV, there are still fragmented primary studies in Ethiopia [
18‐
35]. The majority of the studies showed epidemiologic variations from 0.7% [
28] to 32.0% [
19] over time and across geographical areas. Similarly, a disagreement among those studies about major factors was observed. Therefore, this systematic review and meta-analysis aimed to provide a pooled national estimate of the prevalence of MTCT of HIV and its associated factors in Ethiopia. The result of this study may help to guide policy and decision makers in the prevention and control of MTCT of HIV.
Discussion
Our meta-analysis aimed to estimate the pooled prevalence of MTCT of HIV and its associated factors in Ethiopia. In this meta-analysis, the overall pooled prevalence rate of MTCT of HIV was 11.4%. In addition, sociodemographic, natal, and clinical and drug-related factors were found to be the predictors of MTCT of HIV.
The prevalence of MTCT of HIV in the current study was higher than 2013 United Nations Program on HIV/AIDS reports in South Africa (6%) and in Botswana (2%) [
41]. Low maternal adherence to antenatal care utilization, extensive home delivery, less availability and accessibility of PMTCT interventions and HIV counseling in remote areas, inconsistent availability of infrastructures like roads, light and water and prevailing pre-lacteal feeding habit might cause the higher rate of MTCT of HIV in Ethiopia. Low level of knowledge and awareness of mothers about MTCT of HIV might also attribute to high HIV infection rate among infants in Ethiopia [
42,
43]. Moreover, MTCT of HIV has been eliminated in some countries, like Cuba, Belarus, Armenia, and Thailand [
44]. This might be due to, in these countries, minimized of the pregnant women practiced unprotected sex, women with HIV in those countries didn’t breastfeed their babies, availability of best suited safe and healthy alternative baby formula, good attitudes and perceptions to use HIV drugs during pregnancy, high level of early HIV test before getting pregnant and/or during pregnancy, and persistence implementation of PMTCT after the infants delivered safely.
Although the current finding showed the high burden, it is lower than 2013 UNAIDS reports in Burkina Faso (22%) and in Ethiopia (25%) [
41]. The possible reasons for such discrepancy might be related to year of the study, and an emerging of new strategies and improvement on HIV prevention and control activities.
The subgroup analysis revealed that there was a significant variation among regions. Infants born from HIV-positive mothers in Amhara region had lower rates of MTCT of HIV compared to Addis Ababa and Oromia regions. However, this finding was inconsistent with the 2016 Ethiopia Demographic Health Survey (EDHS) reports in Addis Ababa and Amhara region [
16]. This discrepancy might be due to the fact that there might be the change in the epidemiological transitions of diseases, on and off interventions as per the prevailing HIV cases, the difference in HIV-test coverage, and the difference of awareness to HIV.
According to this study, infants from the rural residence were nearly four times more likely to acquire HIV infection from their mothers. This could be due to living in rural area of Ethiopia, low knowledge to MTCT of HIV, the high proportion of mothers unaware of their HIV status, lack of clinic-based education and counseling [
45], lower level of education, belonging to lower wealth, and not exposed to mass media [
46].
In this study, infants delivered at home were nearly three times more likely to get HIV infection compared to infants delivered at health institutions. This finding was in agreement with a study conducted in Nigeria [
47] and Zimbabwe [
48]. This could be due to home delivery lack implementation of HIV prevention strategies as it does in the health institution. The 90% of HIV-infection among infants born from seropositive mothers is higher during labor and delivery [
5], particularly in the absence of integrated HIV services. The previous study [
49] in Africa showed infants who delivered at home were more prone to many harmful traditional practices that promote HIV-infection rate, such as cord-cutting by shared razor, placental blood contamination, uvulectomy, unplanned circumcision, pre-lacteal feeding, and breastfeeding from unexamined nipples.
This study also showed that HIV-exposed infants who didn’t take ARV prophylaxis and whose mothers didn’t receive prophylaxis during pregnancy and/or breastfeeding were nearly six times more likely to get HIV-infection. This finding was in line with a study conducted in Cote'devore [
50], South Africa, and sub-Saharan Africa [
51,
52]. There is also evidence that showed not initiating ARV prophylaxis to the infant is a risk factor for MTCT of HIV [
53,
54]. This is due to the fact that without ARV drugs a potential effect of HIV transcription, replication, and fusion increased in the human body [
55]. Besides, those infants whose mother couldn’t get PMTCT intervention were 5 times more likely to have HIV infection. This finding was in agreement with studies done in Kenya [
56,
57]. PMTCT strategies are considering prevention of HIV infection among women, prevention of unwanted pregnancy, antenatal protection of fetus, test and counseling of pregnant women, ARV prophylaxis, and treatment of pregnant women. Therefore, MTCT of HIV could highly observable among those mothers lacked PMTCT interventions.
Mixed infant feeding practice also identified as a key predictor of high rate of MTCT of HIV; infants who received mixed feeding were seven times more likely to acquire HIV infection compared to those exclusively breastfed. This finding agreed with studies in South Africa [
58] and Zimbabwe [
59]. Mixed feeding practices may cause laceration of gastrointestinal mucosa which would create a favorable entry of the virus into the bloodstream.
MTCT continues to be a devastating clinical and/or public health burden in Ethiopia. Adequate emphasis has not been given on this pandemic which might lead to increased hospitalizations, cost of healthcare services and reduction of the overall economic structure of the nation. It could be reduced if all women delivered at health institutions. To achieve the WHO’s end AIDS strategy [
11], Ethiopia planned to create “HIV-free generation by the year 2020” [
13] and implementing the health policy that focused on PMTCT and other infectious diseases. However, the burden of MTCT of HIV remains high in the Ethiopian population. Thus, the finding of this study would be important to develop further HIV control interventions and may have a significant impact on health service resource utilization. It also contributes to the growing need for undertaking ART. It will have direct or indirect importance in providing information to the Joint United Nations Programme on HIV/AIDS and partners, 90–90-90 targets; 90% of all HIV-positive persons identified, provide antiretroviral therapy (ART) for 90% of those diagnosed, and achieve viral suppression for 90% of those treated by 2020.
Strength and limitation
This study as it is the first systematic review and meta-analysis that provided the national prevalence estimate on MTCT of HIV. In addition, the effects of three key predictors of MTCT of HIV were estimated. On the other hand, given the limited number of studies, the result may not represent the national figure. Furthermore, the time-trend analysis was not conducted because studies were not available in all the year.