Background
Human immunodeficiency virus (HIV) is a virus that weakens the immune system of an individual exposing the body to several opportunistic infections [
1]. Although the main mode of HIV transmission is through unprotected sexual intercourse, a significant number of vertical transmission also occurs from mother to child. Mother to child transmission (MTCT) is when HIV is transmitted from the mother to the child during pregnancy, childbirth, or breastfeeding [
1‐
3].
The prevalence of HIV/AIDS has rapidly increased since the 1980s in developing countries. As a result, it has led to several demographic, economic and social consequences [
4]. More than 2 million children are living with HIV/AIDS globally, in which more than 80% of them live in sub-Saharan African countries [
5]. For example in 2012, 260,000 new pediatric HIV infections occurred, and most of these infections were in Sub-Saharan Africa [
6]. The most seriously affected areas in Africa include Southern and Eastern African countries [
4]. Hence, the United Nations Program on HIV/AIDS (UNAIDS) set the 90-90-90 target by 2020. The target aims to end the epidemics of HIV by 2030 [
7]. The post-2015 HIV priorities plan to dramatically reduce the annual new HIV infection and thereby to save the lives of many peoples [
8,
9].
Ethiopia is one of the Eastern African countries with adult HIV prevalence of 1.5% in the population aged 15–49 years old. The prevalence is relatively higher among women than men, with a prevalence of 1.9 and 1.0%, respectively [
1]. In 2013, there were more than 160,000 HIV positive children (aged less than 15 years’) in Ethiopia. In addition, the number of orphaned children due to HIV/AIDS were 800, 000. Even though there are a higher number of children with HIV, ART coverage among children was only 12% in the same year [
10]. Nonetheless, studies conducted in Ethiopia have shown that the fertility desire among HIV-positive women is still high [
11]. For this reason, the Ethiopian Federal Ministry of Health (FMOH) adopted a prevention of mother to child transmission (PMTCT) program aimed at eliminating mother to child transmission of HIV in 2011. PMTCT is a program designed to provide effective interventions during pregnancy, labor and delivery and breastfeeding period for the mother and the baby. The intervention includes the provision of ARV drugs for the mother and the baby and HIV preventive practices. In the absence of such interventions, the risk of MTCT of HIV is 15 to 45% [
9]. But through the use of ARV drugs and appropriate preventive mechanisms, the risk can be reduced to less than 5% in under-resourced settings like Ethiopia [
2,
3,
9].
Few studies have been conducted on the prevalence of MTCT of HIV and its associated factors in Ethiopia. However, available studies present inconsistent and inconclusive findings in the prevalence of MTCT of HIV and its associated factors. Therefore, this systematic review was conducted to assess the prevalence and factors associated with mother to child transmission of HIV in Ethiopia using available published evidence. The findings of this study will be useful in the design and implementation of proper strategies to reduce the high rate of MTCT of HIV. Likewise, it will be used to monitor the progress of PMTCT program towards Sustainable development goal (SDG-3), target 3.1, 3.2, and 3.3, which aims to ensure healthy lives, end preventable deaths of newborn, and end the epidemics of AIDS by 2030 [
12].
Discussion
This meta-analysis was conducted to identify the pooled prevalence of MTCT of HIV and its associated factors in Ethiopia using the available published studies. The review found a higher prevalence of MTCT of HIV in Ethiopia, with the overall pooled prevalence of 9.93% (95%CI: 7.29, 12.56). This progress made is far from what the country had planned to achieve. The post-2015 e-MTCT objective by the nation is to reduce vertical HIV transmission to less than 2% by 2020 [
8,
28]. In contrast to the finding of the current study, the previous study conducted in China showed a lower prevalence of MTCT of HIV, 3.9% (95% CI; 3.2, 4.6%) [
29]. While a study conducted in South Africa showed a 14% prevalence of MTCT of HIV among infants younger than six weeks and the prevalence was 24% among children aged 3 to 6 months old [
30]. A wide variation in the prevalence of MTCT of HIV between developed and developing countries can be attributed to the difference in the sociodemographic, economic, access to Antiretroviral (ARV) drugs, health care coverage and health-seeking behavior of the populations. The poor uptake of PMTCT service in developing countries could also be mentioned as a reason for the higher prevalence of MTCT of HIV. Individual-level factors (poor knowledge of pregnant women, lower level of maternal education, and psychological issues) and community level factors (stigma and fear of disclosure) are the common barriers for poor uptake of PMTCT service [
31]. Therefore, addressing individual and community level barriers for poor PMTCT service uptake is important to reduce the high rate of MTCT of HIV in Ethiopia [
31].
One of the PMTCT interventions recommended by WHO is the provision of ARV prophylaxis immediately after birth for 6–12 weeks [
9]. The duration of infant ARV prophylaxis depends on the ART adherence status of the mother [
9]. Nevirapine (NVP) prophylaxis is recommended for six weeks duration for infants who are breastfeeding, and for 4 to 6 weeks of NVP prophylaxis for infants who are not breastfeeding [
6]. The meta-analysis of this review showed that infants who didn’t receive ARV prophylaxis at or after birth are more than seven times more likely to be HIV-infected than an infant who received ARV prophylaxis. Several studies also mentioned the importance of infant ARV prophylaxis in preventing mother to child transmission of HIV [
6,
32]. The ARV prophylaxis given to the infant serves as pre or post-exposure prophylaxis to HIV and it can protect the infant against the HIV especially during breastfeeding [
6,
32,
33].
This review also found that infants who were on mixed feeding before the age of six months were more than seven times more likely to be HIV positive than infants who were on exclusive breastfeeding. This could be because mixed feeding is associated with gastrointestinal ulceration secondary to diarrheal disease. As a result, the virus can quickly enter the infant’s bloodstream through the ulcerated gastrointestinal tissue [
6,
9,
34,
35]. In light of this, WHO and the current Ethiopian national PMTCT guideline recommends the use of safe infant feeding options which include: exclusive breastfeeding for the first six months and initiating complementary foods at six months to 12 months of infant’s life and to avoid mixed feeding before six months of infant’s life [
9,
34]. A study conducted in Nigeria also showed a higher risk of HIV infection among HIV exposed infants who were on mixed feeding [
36].
The use of skilled delivery attendance at birth can reduce the risk of morbidity and mortality for both the mother and the child [
1,
37]. The current review also found that HIV positive mothers who deliver at home were five times more likely to have HIV positive child than HIV positive women who attended skilled birth attendant at a health facility. This could be due to the lack of PMTCT interventions during and immediately after labor and delivery for mothers who gave birth at home. Moreover, interventions available at health facilities include the use of standard infection prevention practices, use of partograph to follow the progress of labor, use of ARV prophylaxis, and safe delivery practices [
9,
34]. A study conducted in western Europe also found that delivery of the baby by elective cesarean section can prevent mother to child transmission of HIV [
38]. A similar finding was also observed in a study conducted in Italy [
39].
The presence of PMTCT intervention during pregnancy, labor and delivery, and breastfeeding period is essential in the reduction of the HIV-positive child [
9]. The findings of this review showed that HIV positive women with no PMTCT intervention were more than seven times more likely to have HIV positive child. Likewise, without any maternal and/or child PMTCT intervention, 20 to 45% of infants will be HIV-infected [
2,
3,
9]. This could be due to the benefits of ARV drugs in reducing maternal viral load, and thereby reducing the risk of HIV transmission from mother to the child [
9,
28]. WHO report also showed that ARV prophylaxis to a woman and her infant could reduce the risk of mother to child transmission to less than 2% [
40].
This review strictly followed the PRISMA guideline during the review and meta-analysis process. All eligible studies on MTCT of HIV were included. However, only studies published in the English language were included. Unpublished research works or government reports were not included in this review. Furthermore, this review included only a few variables associated with MTCT of HIV in Ethiopia, because of the limited number of studies. However, previous studies mentioned older maternal age [
26], HIV positive mothers who didn’t follow antenatal care [
22], late enrolment to HIV exposed infant follow up clinic [
20], short duration of ART regimen [
21,
24], low maternal CD4 count (less than 350 cells/cubic mm) at baseline [
24], mothers on WHO clinical stage 3 and 4 [
22], and low infant birth weight (less than 2500 g) [
24] as additional factors associated with MTCT of HIV. The outcome variable may also be affected by other confounding variables not mentioned in this review. Therefore, further nationwide study to assess personal, health service factors and policy-related reasons for a higher rate of MTCT of HIV in Ethiopia is recommended.
Conclusions
The country has made good progress in reducing the rate of mother to child transmission of HIV. However, the rate of reduction is slow to achieve the elimination of mother to child transmission of HIV goal by 2020. Moreover, this review showed that almost one in every ten HIV-exposed infants become HIV positive. The prevalence of MTCT of HIV varies across different regions of the country. Higher risk of MTCT of HIV was observed among HIV exposed infants who didn’t take ARV prophylaxis, who were on mixed feeding before six months of age, who were delivered at home, and whose mother was not on PMTCT intervention. This calls the Ministry of Health and other concerned partners to focus on the identified factors and work towards improving the PMTCT program. The use of ARV prophylaxis by the mother during pregnancy, and breastfeeding period, and use of infant ARV prophylaxis should be strengthened. HIV testing and counseling programs for women and their partner should be enhanced at antenatal, labor and delivery, and postnatal settings. Also, institutional and community-based comprehensive health education programs on the importance of skilled birth attendance, postpartum care and maternal and infant PMTCT interventions is essential. Further studies to identify the national prevalence and possible additional associated factors especially in regions with higher prevalence of MTCT of HIV are needed.