Tilaye et al. BMC Pediatrics(2024) 24:597
https://doi.org/10.1186/s12887-024-05061-x

BMC Pediatrics

RESEARCH

Open Access

Incidence of mother-to-child transmissionof HIV and predictors of positivity among
HIV exposed infants in South Gondar public
hospitals, Northwest Ethiopia: competing risk
regression model
Birara Ayichew Tilaye1*, Habtamu Shimels Hailemeskel1, Fikadie Dagnew Baye1, Melese Kebede Hailu2,
Gebrehiwot Berie Mekonnen1, Getachew Arage1, Binyam Minuye Birhane3,4, Nigusie Selomon Tibebu1 andNatnael Moges1
Abstract
Background The principal route of HIV infection in children is vertical transmission. Thus, this study aimed to assess
the incidence of mother-to-child transmission of HIV and predictors of positivity among HIV-exposed infants.
Method Institutions-based retrospective follow-up study was conducted in South Gondar Public hospitals,
Northwest Ethiopia from December 2019 to November 2021. The data were taken from PMTCT logbooks and patient
medical records, with death being the competing event. Data were entered in to Epi info version 7 and exported to
STATA version 14 for final analysis. Both bivariable and multiple variable proportional subdistribution hazard analysis
were conducted to identify predictors. P-value < 0.05 was level of significance.
Result A total of 469 exposed infant mother pairs records were included. The cumulative incidence rate at the endof the study period was 5.2 per 1000 person months (5.2; 95% CI: 3.4-8.0).Infants’ absence of ARV prophylaxis at birth(aSHR = 3.7; 95% CI: 1.33–10.48), Mothers with no PMTCT intervention (aSHR = 5.1; 95% CI: 1.83–14.03), home delivery(aSHR = 4.1; 95%CI: 1.46–11.63) and maternal disclosure of HIV status to partner/families (aSHR = 2.9; 95% CI: 1.06–7.78)
were predictors of HIV positivity.
Conclusion The study found that Infants’ absence of ARV prophylaxis at birth, mothers without PMTCT intervention,home delivery and mothers who were not disclosing their HIV status to families were predictors of HIV positivity.
Keywords HIV, Incidence, Mother-to-child transmission, Exposed infants, Ethiopia*Correspondence:
Birara Ayichew Tilaye
biraraa15@gmail.com
1
Department of Pediatrics and Child Health Nursing, College of Health
Sciences, Debre Tabor University, Debre Tabor, Ethiopia
2
Department of comprehensive Nursing, College of Health Sciences,
Debre Tabor University, Debre Tabor, Ethiopia
3
College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
4
Schools of Public Health, University of Technology Sydney, Sydney, NSW,
Australia© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you
give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified thelicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to thematerial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation
or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://
creativecommons.org/licenses/by-nc-nd/4.0/.

Tilaye et al. BMC Pediatrics(2024) 24:597

Introduction
Globally, in 2020, approximately 4000 new HIV infections
were reported daily, with 60% occurring in sub-SaharanAfrica and 10% occurring in children [1]. Mother-toChild Transmission of HIV (MTCT) during pregnancy,
labor, delivery, or breastfeeding is the main source of HIV
infection, contributing to more than 90% of new HIV
infections. The overall MTCT rate varies from 15 to 45%
in the absence of any intervention [2]. In 2016, there were160,000 new pediatric infections and 120,000 AIDSrelated deaths worldwide [3]. The implementation ofPrevention of Mother-to-Child Transmission (PMTCT)
service cascades, consisting of prophylactic antiretroviral(ARV) medication for HIV-exposed infants (HEIs), lifelong antiretroviral therapy (ART) for HIV-positive pregnant and lactating women, serial HIV testing of infants
and prompt initiation of ART among infants who become
HIV-positive, is crucial for reducing the rates of MTCTof HIV and new infections in children [4, 5]. A numberof factors influenced MTCT of HIV. The place of delivery, route of delivery, infant prophylaxis, infant feedingpractices [6], residence, antenatal care visits(ANC), CD4cell counts during pregnancy, and infant birth weight lessthan 2.5 kg [4, 7] are factors for the acquisition of HIV
infection in HEIs.
Ethiopia is among the countries most affected by the
HIV/AIDS pandemic. In 2016, 27,104 of the 720,000 people living with HIV were newly diagnosed. However, a
noticeable portion of HIV-positive individuals died, with
only 67% of predicted individuals knowing their HIV
status and 59% enrolling in a highly active antiretroviraltherapy (HAART) program [8]. Additionally, Ethiopia
had 42,000 children aged 0–14 who were living with HIV,
with a 17.9% MTCT rate [9].
To address these challenges, the World Health Organization (WHO) developed the ART guidelines, which
recommend three PMTCT approaches (A, B, and B+) toeliminate HIV infection through MTCT. The most recent
strategy, the Option B+ PMTCT initiative, sets an intense
focus on providing all HIV-positive women access touniversal, lifelong ART, irrespective of their CD4 countand WHO clinical staging [10]. Between 2000 and 2021,
PMTCT intervention averted 2.9 million HIV infections
and 1.5 million maternal and pediatric deaths globally[11].
As part of its national policy to improve maternal survival and prevent new HIV infections in children, Ethiopia has been implementing the Option B+ program since2013 [2, 12]. The percentage of women receiving PMTCT
services in Ethiopia increased from 25.5% in 2010 to 73%
in 2015. As of 2016, only 35% of HIV-positive children
were receiving ART [13]. Despite its best efforts, Ethiopia continues to face a significant health challenge dueto the high rate of HIV morbidity and mortality among

Page 2 of 9

pregnant and lactating women and their infants, placing
it among the 10 countries with a high HIV burden, with
an MTCT rate of 18% [6, 10].Other studies indicated thatthe rate had reached up to 30% [13]. Even though a variety of studies on the incidence, predictors, and MTCTof HIV have been performed in various regions of thecountry, the effect of competing risks like death, wasoverlooked. Therefore, this study aimed to estimate theincidence and Predictors on MTCT of HIV among HIVexposed infants in South Gondar public hospitals, Northwest Ethiopia: Competing risk regression model from
December1, 2019 to November 30, 2021.

Methods and materials
Study area

The study was carried out in the South Gondar Zone,
which is located in the center of the Amhara region andNorthwest part of Ethiopia. The zone is approximately
668 km from Addis Ababa, the capital city of Ethiopia,
and 103 km from Bahir Dar, the regional state of Amhara.
Debre Tabor is the administrative center of the South
Gondar Zone.The Zone has 18 districts, with a total
population of 2,609,823 (1,304,911 females and 1,304,912
men) [14]. There are 48 Health centers and 8 hospitals
which provide PMTCT services for the zone; all of them
are government health facilities. Among the hospitals,
Debre Tabor Hospital is the only comprehensive and specialized referral hospital but the rest are primary hospital[15].
Study design and period

A facility-based retrospective follow-up study was carried out at all PMTCT clinics of the study hospitals.
Data were taken from PMTCT logbooks and medical
records of mother-infant pairs from December 1, 2019 toNovember 30, 2021.
Eligibility criteria

All HEIs up to the age of 24 months who had a DNA/PCR test result at the age of enrollment or a rapid antibody test result at or over 18 months of age after 6 weeks
of breastfeeding cessation during the follow-up period
were included in the study. Besides those HEIs who died
before their HIV status were known included in the
study as competing risks. Infants enrolled in HIV/AIDS
chronic care with no DNA /PCR or rapid antibody test
results (is suspected of having symptomatic HIV or displays any severe classification possibly due to HIV or
has positive antibody test under 18 months and has 2 ormore of the following: oral thrush, severe pneumonia orsevere sepsis. Cases with severe acute malnutrition ormoderate acute malnutrition that does not respond normally to treatment can also enrolled to the chronic care)Tilaye et al. BMC Pediatrics(2024) 24:597

or incomplete records and those lost to follow up at thetime of enrolment were excluded from the study.
Study populations and sampling procedure

To illustrate the Fine and Gray model [16], in this paper,
all mother-infant pairs enrolled in PMTCT service registered in randomly selected hospitals were included. The
selected facilities include: Debre Tabor Comprehensive
and Specialized Hospital, Ibinat and Addis Zemen primary hospitals.
The study population consists of 506 HEIs paired with
their mothers who had enrolled at the PMTCT clinic in
the study hospitals. Of these, 469 infant-mother pairs
were included in the study. Among HEIs 21and 8 of themwere HIV positive and died respectively. Death as a competing risk in the analysis of incidence of MTCT of HIV
to exposed infants can alter the possibility or completely
impede the occurrence of mother-to-child transmission of HIV. This differs from censoring, which simply

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prevents the observation of the time at which verticaltransmission occurred. Those who encounter a competing event are regarded as censored in standard KaplanMeier analysis. This analysis will overrate the likelihoodof MTCT of HIV in exposed infants, as it can no longer
occur in dying individuals. As a result, the Fine and Gray
sub-distribution hazard model approach is preferred over
the Cox regression model in the presence of competingrisk [16–19]. The sampling procedure is shown in (Fig. 1).
The st power command of software Stata 14 at 95% CI
and 80% power with Hazard ratio of 2.31 [7] was used toestimate the minimum sample size for incidence and predictors, resulting in 428 sample size.
Data collection

A checklist derived from a national HIV-exposed infant
follow-up form was used to gather the data. The data
were collected from PMTCT logbooks and medical
records of infants exposed to HIV. Four experienced

Fig. 1 Schematic presentation of the sampling procedure for incidence and predictors on mother-to-child transmission of HIV among HIV-exposed
infants

Tilaye et al. BMC Pediatrics(2024) 24:597

nurses trained in PMTCT and comprehensive HIV carecollected the data.
Data analysis

After collection, the data were checked for consistency
and completeness, entered into Epi Info version 7, andexported to Stata version 14 for further analysis. The
variables under study were described using descriptive
statistics, including frequency, percentage, and mean. To
predict the cumulative incidence, which was expressed
per 1000 person-months, we employed competing risk
regression with a proportional subdistribution hazard
model. Variables in the bivariable proportional subdistribution hazard model with p values less than 0.25 were
included in the multivariable analysis. For the overallmodel fitness, the model assumption was tested using the
Schoenfeld residual and the Cox-Snell residual plots. The
results were considered statistically significant at p < 0.05.
The strength of the association was assessed using thecrude subhazard ratio (cSHR) and adjusted subhazard ratio (aSHR) with their respective 95% confidence
intervals.
Dependent variable

Incidence of MTCT of HIV was the outcome variable,
while death was a competing event. At the end of thestudy period, subjects were categorized as either HIVpositive, died, lost to follow up or censored.
Independent variables

HEIs and their mothers’ socio-demographic variables (age of the mother, maternal educational status,
residence).
Follow up history during pregnancy (antenatal
follow-up).
Intrapartum influences (place of delivery, mode ofdelivery).
Therapy and clinical variables (maternal ARV therapy,
infant ARV prophylaxis, and maternal CD4 count).
Operational definition
Sero-status

Dried blood spot (DBS) or rapid antibody test results
were considered positive or negative for HIV during the
24-month follow-up period, as indicated by the infant
registration chart (6).
HIV exposed infants (HEIs)

Infants born to HIV-infected mothers or HIV antibody
test positive for infants < 18 months of age.
Mother to child transmission (MTCT) of HIV

Determined by the infant’s final (confirmed) HIV test
result and classified as:Page 4 of 9• 	 For breastfed infants: - HIV DNA/PCR resultfor infants aged < 18 months after cessation ofbreastfeeding or HIV antibody test result for
infants aged ≥ 18 months 6 weeks after cessation ofbreastfeeding.
• 	 For non-breast-fed infants: - HIV DNA-PCR resultfor infants aged < 18 months or HIV antibody test
result for infants aged ≥ 18 months.
Competing risks are events which prevent the occurrence or modify the risk of the primary event or outcomeof interest [16].
Ethical consideration

Ethical approval was obtained from Debre Tabor University, College of Health Sciences, Ethical Review Committee. A consent letter was then sent to the study hospital
to collect data with no informed consent from the study
subjects as the data was secondary. The data retrieved
from the study hospitals’ HEIs’ records and PMTCT
registration logbooks were used totally anonymous. The
data are all kept confidential.

Results
Socio-demographic characteristics of infant

The study population comprised 506 HEIs - mothers’
pairs who attended PMTCT clinics in the study public
hospitals. The study involved 469 participants and hada retrieval rate of 92.7%. At the time of enrolment, themean age of exposed infants was 5.12 (± 2.5). About halfof the participants were male. Most mothers (62.9%) were
married, 25.4% were single, and 11.7% were divorced andwidowed, with 72.7% living in urban and more than two
thirds (69.3%) of the participants being literate.
Most mothers (91%) delivered through the vagina
spontaneously. More than two-thirds of HEIs (69.5%)
were born at health facilities with 83.2% of the mothers
having antenatal follow-ups. The majority of the mothers(86.4%) disclosed their HIV- status to their partners andfamilies. Roughly 80% of both mothers and their exposed
infants were on HAART and ARV prophylaxis respectively. The majority of HEIs (74.2%) were fed on exclusive
breastfeeding in the first six months (Tables 1).
Cumulative incidence rate (CIR) of MTCT

A competing risks analysis correctly determines theabsolute risk of a time-to-event outcome of interest
by incorporating the competing event into the analysis [20]. A total of 469 participants were followed for aminimum of 4.25 months and a maximum of 24 months,
with a median follow-up time of 9.27 months. The total
risk observed during the follow-up period was 4048.88
person-months. The overall CIR by the age of 24 months

Tilaye et al. BMC Pediatrics(2024) 24:597

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Table 1 Demographic and clinical characteristics of HIV-infected
women and their exposed infants
Maternal age
15–24
25–34
>=35
Marital status
MarriedSingleDivorced and widow
Residence
Urban
Rural
Educational Level
Primary and above
Illiterate
Maternal Disclosure of HIV status topartners/families
Yes
No
ANC
Yes
No
Place of delivery
Health facility
Home
Mode of delivery
Spontaneous vaginal delivery
Caesarean section
PMTCT
Yes
No
Sex
FemaleMaleBirth Weight of the infant≥ 2500 gram< 2500gram
Infant ARV prophylaxis
Yes
No
Feeding (1st six months)
EBF
ERF
MF
Maternal CD4count during pregnancy
≥ 350
< 350

Frequency

%

176
234
59

37.53
49.89
12.58

295
119
55

62.90
25.37
11.73

341
128

72.71
27.29

326
143

69.51
30.49

405
64

86.35
13.65

390
79

83.16
16.84

377
92

80.38
19.62

427
42

91.04
8.96

378
91

80.60
19.40

232
237

49.47
50.53

418
51

89.13
10.87

371
98

79.10
20.90

348
45
76

74.20
9.59
16.20

323
146

68.87
31.13

was 5.2 per 1000 person-months 5.2 (95% CI: 3.4-8.0)
as shown in Table 2. At the end of the study period, thehighest CIR (about 11 per 1000 person-months) was
observed in children born at home, those whose mothers

did not disclose their HIV status to one’s partner/families
and mothers who were not on PMTCT. The overall transmission rate of HIV infection from HEIs was estimatedto be 4.5% by the end of the study period (4.5%;95% CI:
3–7%).
Predictors of mother-to-child transmission of HIV

The subdistribution hazard ratio (SHR) for selectedcovariates with death as a competing event was obtained
from Fine and Gray competing risk survival regression
model [16] for different predictors of HIV positivity for
HEIs are given in Table 3.
Schoenfeld residual global test was 0.3502 which fulfilled the sub-hazard proportionality assumption andshowed that the goodness-of-fit test was satisfactory(Fig. 2).
Several factors in the bivariate subdistrbution hazard
analysis < 0.25 were included in the multi variate analysis(Table 3).
Infants who did not receive ARV prophylaxis at birth(aSHR = 3.7; 95% CI: 1.33–10.48), mothers who did notreceive PMTCT intervention (aSHR = 5.1; 95% CI: 1.83–
14.03), mothers who did not disclose their HIV status
to partners/ families (aSHR = 2.9; 95% CI: 1.06–7.78)
and mothers who delivered at home (aSHR = 4.1; 95%CI:
1.46–11.63) had a significant association with HIV transmission among HIV-exposed infants according to multivariate subhazard regression analysis.

Discussion
Predictors on MTCT of HIV among HIV-exposed infants
include the absence of infants’ ARV prophylaxis, motherswith no PMTCT intervention, mothers failing to disclose
their HIV status to their partners or families, and homedelivery. By the age of 24 months, the overall incidence
rate of MTCT of HIV among HEIs in the study public
hospitals was 5.2 per 1000 person-months, with an overall vertical transmission rate of 4.5% which is a substantial burden for our society. The finding of this study wasconsistent with retrospective studies conducted in Ethiopia, like Dessie (3.8%) [21], Gondar (5.5%) [3], and west
Guji zone (3.8%) [22]. The similarity might be due to theimplementation of a similar PMTCT program.
The result of our study was lower than studies conducted in India, Vietnam and Southwest Ethiopia [7, 12,23] but higher than studies in Northern Ethiopia(2.1%)[24] Nigeria(2.8%) [4] and Rwanda(2.2%) [25].This discrepancy might be attributed to spatial differences, as ourstudy was conducted during a period of high ART coverage for pregnant and lactating women, unlike earlier
research in the country. The study findings could also be
influenced by variations in sociodemographic characteristics [13, 26].

Tilaye et al. BMC Pediatrics(2024) 24:597

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Table 2 Cumulative incidence rate (per 1000 person-months) by the end of the 24 months
Variables

HIV Negative
infants

HIV positive
infants

Maternal age
15–24
166
7
25–34
222
9
>=35
52
5
Marital status
Married280
11Single111
6Divorced and widow
49
4
Residence
Urban
321
15
Rural
119
6
Educational Level
Primary and above
307
15
Illiterate
133
6Maternal Disclosure of HIV status to partners/families
Yes
384
15
No
56
6
ANC
Yes
371
14
No
69
7
Place of delivery
Health facility
361
12
Home
79
9
Option B+ PMTCT
Yes
359
12
No
81
9
Mode of delivery
SVD
401
19
C/S
39
2
Sex
Female
217
10
Male
223
11
Birth Weight of the infant≥ 2500 gram395
17
< 2500gram
45
4Infant ARV prophylaxis
Yes
353
13
No
87
8
Feeding in 1st six months
EBF
331
13
ERF
42
2
MF
67
6
Maternal CD4 at pregnancy
≥ 350
302
15
< 350
138
6
Total
440
21

The multivariate analysis included several covariates from the bivariate subhazard analysis withp-values < 0.25.
Absence of infants’ ARV prophylaxis at birth was nearly
three times more likely to contract HIV than infants who

Death

Person-months

CIR(95% CI)3
3
21333.692045.87669.3200.00520.00440.0075(0.0025–0.0110)(0.0023–0.0085)(0.0031–0.0179)

42
22441.451012.2595.230.00410.00690.0067(0.0022–0.0076)(0.0033–0.0145)(0.0025–0.0179)

532812.911235.97

0.00500.0057(0.0029–0.0084(0.0027–0.0119)

5
32635.591413.290.00570.0042(0.0034–0.0094)(0.0019–0.0094)

623502.81546.070.00430.0110(0.0026–0.0071)(0.0049–0.0245)

5
33046.101002.780.00460.0070(0.0027–0.0078)(0.0033–0.0146)

443250.11798.770.00370.0113(0.0021–0.0065)(0.0059–0.0217)

5
33246.56802.320.00370.0112(0.0021–0.0065)(0.0058–0.0216)

7
13648.17400.710.00520.0050(0.0033–0.0082)(0.0012-0.0200)

532073.231975.651

0.00480.0056(0.0026–0.0090)(0.0.0031–0.0101)

6
23561.10487.780.00480.0082(0.0030–0.0077)(0.0031–0.0218)

5
33198.66850.220.00410.0094(0.0024–0.0070)(0.0047–0.0188)

4
1
32764.61418.36865.910.00470.00480.0069(0.0027–0.0081)(0.0012–0.0191)(0.0031–0.0154)

62
82562.021486.864048.880.00590.004
0.0052(0.0035–0.0097)(0.0018–0.0090)(0.0034–0.008)

got prophylaxis. This study was congruent with previous studies in Northwest Ethiopia [2, 6, 27], Uganda [28]and Nigeria [29].Since MTCT of HIV is greater during labor and delivery, starting ARV prophylaxis for the
HEIs immediately after birth will hinder the replication

Tilaye et al. BMC Pediatrics(2024) 24:597

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Table 3 Predictors on MTCT of HIV among HIV-exposed infants
on the PMTCT clinics by the end of 24 months
Characteristics
Maternal age
15–24
25–34
≥ 35
Residence
Urban
Rural
Educational status of mothers
Primary and above
Illiterate
Maternal Disclosure of HIV
status to partners/families
Yes
No
ANC
Yes
No
Place of delivery
Health facility
Home
PMTCT
Yes
No
Maternal CD4 at pregnancy
≥ 350
< 350
Infant ARV prophylaxis
Yes
No

cSHR (95% CI)

aSHR (95%CI)

10.79(0.29–2.16)
0.45(0.15–1.38)

0.92(0.33–2.53)
0.52(0.14–1.92)

1.68(0.71–3.95)
1

1.24(0.41–3.66)

10.38(0.16–0.95)

0.44(0.16–1.23)

1
3.75(1.53–9.20)**

2.88(1.06–7.78) **1
0.44(0.17–1.13)

0.50(0.16–1.61)

1
2.87(1.16–7.09)*

4.12(1.46–11.63)***

1
4.84(2.0611.43)***1
0.33(0.1–0.92

5.07(1.83–14.03)***

0.63(0.20–2.03)
1

2.67(1.01–7.07)*

Feeding in the first six months
Exclusive breastfeeding
1
Exclusive replacement feeding 0.70(0.20- 2.41)
Mixed feeding
0.45(0.15–1.31)

3.73(1.33–10.48)**

0.61(0.070–5.22)
0.54(0.13–2.21)

P value *=<0.05; ** =<0.01; ***=<0.001.

of the virus thereby reducing the chance of vertical HIV
infections in newborns. The study by Trials Network 040/
Pediatric AIDS Clinical Trials Group 1043 found that
2-drug or 3-drug short-course regimens provided equivalent protection against infection in infants of mothers
who delivered before treatment with peripartum transmission rates of 2–3% [30].Therefore commencing ARV
prophylaxis promptly will reduce MTCT unlike previous
studies [12, 13].
This study found that HAART during pregnancy anddelivery significantly reduce the risk of HIV infection in
infants exposed to the virus.
The hazards of mothers without PMTCT intervention were four times more likely to have HIV-positive
children at the end of the follow-up period. This finding

Fig. 2 Goodness-of-fit test for the Cox-Snell residual plot for incidence
and predictors on MTCT of HIV among HEIs

was similar with studies in Ethiopia [12, 13, 27, 31, 32],
and studies in other African countries [33, 34]. The rational could be PMTCT interventions reduces maternal
viral load during pregnancy, labor or in breast milk and,
therefore, could substantially lower the risk of motherto-child HIV transmission. The rate of MTCT has been
decreasing over time in parallel with the increased coverage of ART intervention for women during pregnancy.
In Africa, during the analysis of 32 countries with generalized HIV epidemics, Hill et al. noticed that an average 10% increase in PMTCT coverage was related to a
3–3.5% reduction in MTCT rate [35].
Mothers who did not reveal their HIV status to theirpartners /families were about two times more at risk ofpassing HIV to their children than who did. This study
was in line with studies in Kenya [36, 37], Malawi [38]and South Africa [39]. Maternal HIV status disclosure
facilitate timely access to PMTCT and other services for
women and their exposed infants, as it encourages themto seek support from their partners and family [1, 39].
Home-delivered mothers were found to be three times
more likely to experience MTCT of HIV compared tothose who gave birth in hospitals. Our study results are
similar to results from studies conducted in Ethiopia andChina [2, 23, 27, 31, 32]. The absence of PMTCT interventions during and after labor and delivery for mothers
who gave birth at home might cause their HEIs to contract HIV infection. Home-delivered women will also
miss interventions offered at health institutions, such as
the use of standard infection control procedures, the useof partographs to track labor progress, the use of ARV
prophylaxis, and safe delivery procedures [6]. Moreover,home-born infants are more vulnerable to harmful traditional practices such as cord-cutting, placental blood
contamination, uvulectomy, unplanned circumcision,and pre-lacteal feeding [27], hence increasing the risk of
HIV infection.

Tilaye et al. BMC Pediatrics(2024) 24:597

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Conclusion and recommendation
The study found that infants’ absence of ARV prophylaxis
at birth, mothers without PMTCT intervention, homedelivery and mothers who were not disclosing their HIV
status to partner/families were predictors of HIV positivity. To avert new HIV infection, all HIV positive pregnant women should start lifelong ART regardless of CD4
count and WHO clinical staging since over 90% of all
new pediatric HIV infections are due to MTCT.
To eliminate the global MTCT of HIV, it is necessary
to expand the PMTCT interventions. So, MTCT of HIV
can be almost completely prevented if both the motherand the infant receive ARV treatment as early as possible
during pregnancy and after birth. As a result, there is still
more to be done to further reduce MTCT in Ethiopia,
as the MTCT rate in the UK has already dropped to lessthan 1%, while HIV MTCT has been eliminated in Cuba,
Thailand, and Belarus.

Data availability
The data that support the findings of this study are available from thecorresponding author upon reasonable request.

Strength and limitation of the study

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Strength

our study applied competing risk variable (death) using
Fine and Gray competing risk model.
Limitation

Since this research was based on data collected retrospectively from follow up records, all risk factors of
MTCT data were not fully available. Besides, our study
doesn’t indicate cause and effect relationships as it is not
randomized controlled trial.
Abbreviations
ANC	Antenatal careART	Antiretroviral therapy
ARV	AntiretroviralaSHR	Adjusted sub hazard ratio
CIR	Cumulative incidence ratecSHR	Crude sub hazard ratio
DBS	Dried blood spot
DNA-PCR	Deoxyribonucleic acid polymerase chain reaction
EBF	Exclusive breastfeeding
EID	Early infant diagnosis
HAART	Highly active antiretroviral therapy
HEI	HIV-exposed infantHIV	Human immunodeficiency virus
MTCT	Mother to child transmission PMTCT: Prevention of mother-tochild transmission
Acknowledgements
We would like to express our heartfelt gratitude to Debre Tabor, Ibinat andAddis Zemen Hospitals administrators, technical staffs and all those who havecontributed to this research project to be true.
Author contributions
Authors(BAT, HSH, FDB, MKH, GBM, GA, BMB, NST, NM) participated in thedesign, data collection, data analysis and interpretation. And authors (BAT,
HSH, FDB, MKH) participated in the drafting of the manuscript. All authors readand approved the final manuscript.
Funding
This research didn’t receive any grant from any funding agency in the public,commercial, or not-for-profit sectors.

Declarations
Competing interests
The authors declare no competing interests.
Ethical approval and consent to participate
Ethical approval was obtained from Debre Tabor University; College of Health
Sciences and a formal letter of cooperation was written to the administratorsof the respective hospitals. Since the study was a retrospective follow up
study, waiver of consent was approved by the ethical review committee of thecollege of health science of Debre Tabor University. The collected data were
kept confidential.
Consent for publication
Not applicable.
Received: 1 March 2024 / Accepted: 5 September 2024

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