Prevalence of HIV1 Infection and Its Associated Factors among Exposed Infants at Shegaw Motta General Hospital, Ethiopia

1 1 Prevalence of HIV1 Infection and Its Associated Factors among Exposed 2 Infants at Shegaw Motta General Hospital, Ethiopia 3 Destaw Kebede Nigusie 1, 2 * Fantahun Getaneh Damitew 1 , Kirubel Endalamaw Melsew 1, 4 Girma Zerefaw 3 , Abebe Feneta Nigusie4 5 1 Department of Diagnostic Medical Laboratory Science at Shegaw Motta General Hospital, 6 East Gojjam, Motta Town, Ethiopia, 7 2 Department of Bacteriology and Mycology Reference Laboratory, Amhara Public Health 8 Institute (APHI)- Debre Markos Branch, Debre Markos Town, Ethiopia 9 3 Department of Molecular Biology and Virology Reference Laboratory, Amhara Public Health 10 Institute (APHI), Bahir Dar Town, Ethiopia 11 4 Department of Medical Laboratory science, College or Medicine and Health science, Debre 12 Markos University, Debre Markos Town, Ethiopia 13 14 *Correspondence Author, [email protected] 15 16 17 18 19 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. 2 20 Abstract 21 Background: Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome is a 22 leading cause of death and disease burden. Following this, vertical transmission is the main 23 source of HIV infection on children globally. Morbidity and mortality among HIV-exposed 24 infants are still the main health challenges in Ethiopia. Therefore, the aim of this study was to 25 determine the prevalence of HIV1infection and its associated factors among exposed infants at 26 Shegaw Motta General Hospital, Ethiopia. 27 Methods: Hospital-based cross-sectional study was conducted on exposed infants at Shegaw 28 Motta General Hospital from September 1, 2022 to July 30, 2023. The consecutive convenience 29 sampling technique was used to select study participants. Whole blood sample was collected 30 from mothers and infants. Laboratory tests like early infant diagnosis, cluster of differentiation 4 31 counts and viral load were performed using standard operating procedure. Then, the data were 32 entered into EpiData version 3.1 and analyzed by SPSS version 20. Finally, bivariable and 33 multivariable logistic regressions were carried out to identify factors significantly associated 34 (P<0.05). 35 Results: Out of 155 infants, about 79(50.9%) infants were females and87(56.1%) was urban 36 resident. Furthermore, majority of infants were born from mothers who could not able to write 37 and read 88(56.8%) and maternal ages range from 25-34years were 138(89.0%). The overall 38 prevalence of HIV1 infection among exposed infants was6(3.87%) with (95%CI: 2.9-8.2). 39 Pregnant women had not antennal care (AOR=7.281, P = 0.001), home delivery (AOR= 3.239, 40 P=0.001), maternal not received antiretroviral prophylaxis (AOR = 9.213, P= 0.001), infants 41 not intake nevirapine prophylaxis (AOR=2.560, P= 0.007) and maternal high viral load (AOR= 42 5.120, P= 0.004) were the factors associated with HIV infection among exposed infants. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 3 43 Conclusion: The HIV1 infection among exposed infants was still high (3.87%). Pregnant 44 women had not antenatal care follow up, home delivery, maternal high viral load, and not 45 receiving antiretroviral prophylaxis, infant not intake nevirapine prophylaxis increases the risk 46 of HIV1 infection. Therefore, health facilities should strictly strengthen the PMTCT service by 47 providing maternal antiretroviral prophylaxis, infant nevirapine prophylaxis, promoting 48 antenatal care service, early screening maternal viral load and scale up skilled delivery to 49 eliminate HIV infection among exposed infants. 50 Keywords: HIV infection, associated factors, exposed infants, Ethiopia 51 Introduction 52 Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a 53 leading cause of death and disease burden [1]. Following this, vertical transmission is the main 54 source of HIV infection in children with an estimated 2000 vertically-acquired HIV infections 55 occurring daily in global and mostly in Eastern Europe and Central Asia [2]. However, about 56 330,000 children were infected with HIV in 2011 globally, with over 90% of these infections 57 through mother-to-child transmission was illustrating in sub-Sahara Africa [3]. 58 Ethiopia is one of these priority countries where every 3 children born to women living with HIV 59 still gets infected with HIV [4, 5]. So, infants acquire infection with HIV-1 through mother-to- 60 child transmission (MTCT) of the virus [6]. MTCT of HIV-1 can occur through intrauterine (IU), 61 at the time of labor and delivery or intra-partum, and postpartum mainly through breastfeeding 62 [7,8].In addition to prenatal antiretroviral therapies, public health strategies such as prevention of 63 maternal nipple lesions, mastitis and infant thrush; reduction of breastfeeding duration by all . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 4 64 HIV-1-infected mothers; absolute avoidance of breastfeeding by those at high risk, and 65 prevention of HIV-1 transmission to breastfeeding mothers should be addressed [9]. 66 HIV-1 infection in breastfed children born to infected mothers is associated with the presence of 67 integrated viral deoxy- ribose nucleic acid (DNA) in the mothers' milk cells. IgM and IgA anti- 68 HIV-1 in breastmilk may protect against postnatal transmission of the virus [10]. However, 69 international guidance currently states that when replacement feeding is acceptable, feasible, 70 affordable, sustainable and safe, the avoidance of all breastfeeding by HIV-infected mothers is 71 recommended [11]. 72 Most of the deaths in children with HIV could have been avoided through early infant diagnosis 73 (EID) and provision of effective care and treatment. Interventions like the use of antiretroviral 74 (ART) drugs by infected pregnant women, safe delivery practices and safe infant feeding have 75 helped to reduce the risk of transmission to infants by 40% to 50% [12]. Because of passively 76 transferred maternal HIV-1 antibodies, which may be present in the child's bloodstream until 18 77 months of age, antibody tests are not reliable for diagnosing children less than 18 months of age 78 [12, 13].Instead, polymerase chain reaction (PCR) such as EID provides a feasible method to 79 assess prevention of mother- to child transmission (PMTCT) programs and early identify HIV- 80 infected infants [14] the reason why its high sensitivity and specificity, PCR has been widely 81 used for diagnosis of HIV amongst exposed infants as well as identification of infection from 82 birth [15] 83 Ethiopia is among the top ten countries in the world with the highest burden of HIV1 infections 84 among children [16] with the average number of MTCT of HIV in Ethiopia was 18% [17]. So 85 that, Child morbidity and mortality among HIV-exposed infants are still the main health . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 5 86 challenges in Ethiopia [18]. However, there need a further study beyond HIV 1 and its associated 87 factors among infants born to HIV positive women. Therefore, the aim of this study was to 88 determine the prevalence of HIV 1and its associated factors among infants born from HIV 89 positive mothers at Shegaw Motta General Hospital, Ethiopia. 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 6 105 Materials and Method 106 Study design, area and period 107 Hospital based cross sectional study was conducted at Shegaw Motta General Hospital (SMGH) 108 which is found in East Gojjam zone, Amhara regional state. Shegaw Motta General Hospital is 109 found in Amhara region, which is located at a distance of 120 Km from Bahir Dar and 370 Km 110 away from the capital city of the Ethiopia, Addis Ababa. SMGH has provided service to more 111 than 1.5 million total populations. Whenever, this study was conducted from September 1, 2022 112 to July 30, 2023. 113 Study Population and participants 114 All infants (ages < 12months) born from HIV positive mothers were the study population. While, 115 all HIV exposed infants attending PMTCT clinic in Shegaw Motta General Hospital and 116 providing a blood sample during the study period were study participants. 117 Sample size and sampling technique 118 The sample size was calculated by using single population proportion formula by taking the 119 prevalence of HIV-positive infants born to HIV-positive mothers, 11.4% pooled prevalence in 120 Ethiopia [19] using the assumption of 95% confidence level (Z= Z α/2=95%=1.96), margin of 121 error (d= 5%=0.05), Then, sample size was determined as follows: 122 123 N= (Zα/2)2p (1-p)=155 124 d2 125 Therefore, the minimum of 155 study participants was selected by consecutive convenience 126 sampling technique. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 7 127 Eligibility criteria 128 All infants born to HIV positive mother attending PMTCT clinic at Shegaw Motta General 129 Hospital were included in this study. While, exposed infants who were critically ill and whose 130 parents were unwilling to give their consent were excluded from the study. 131 Data collection and processing 132 The data were collected by trained a midwifery and principal investigator. Thus, socio- 133 demographic and associated factors were collected by semi-structured pre-tested Amharic 134 version questionnaire using a face-to-face interview with parents of study participants directly 135 after obtaining consents. At each data collection spot, sufficient explanation about the aim of the 136 research was given to the parents before conducting the interview. 137 Blood specimen collection, transportation and storage 138 A minimum of 100µlwhole blood specimen was collected using ethylene diamine tetra acetylene 139 (EDTA) test tube as per the manufacturer`s instruction at heal or toe site of the infants who born 140 to HV positive mother [20]. The collected whole blood was transported immediately from 141 PMTCT clinic to Shegaw Motta General Hospital, Microbiology laboratory for Examination. 142 Due to the Cepheid was busy by which GeneXpert MTB/RIF tests were done and the sample was 143 not done immediately, the samples were stored at 2-8oc, 15-30oc and 31-35oc for up to 72, 24 and 144 8 hours, respectively [21]. Additionally, 5ml of whole blood was collected from mother with 145 EDTA K3 plasma separating tube (PPT),wait for 4–12hoursand then centrifuged at 3000 146 rpm for 3minute to separate the 1-2ml plasma from red blood cells. Such separated 147 plasma was stored at 2-8 oCfor a week due to not done immediately. After then, it was . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 8 148 transported to Debre Markos Comprehensive specialized hospital (DMCSH), Molecular 149 biology laboratory at 2-8oC with triple packaging system to determine maternal viral load. 150 Laboratory testing 151 Early Infant diagnosis (EID) by GeneXpert HIV-1 Qual Assay 152 In the newly updated algorithm, samples that are nonreactive or indeterminate in the 153 differentiation assay are to be tested with an HIV-1 nucleic acid amplification (NAAT) test for 154 resolution. Xpert HIV-1 Qual assay is a new NAAT assay approved for the identification of HIV 155 infection in whole blood [21]. 156 GeneXpert HIV-1Qual assays were conducted according to manufacturer’s recommendations. 157 EID could be done by the GeneXpert HIV-1 Qual Assay using GeneXpert system machine 158 (Cepheid)[22] by trained laboratory personnel during the study period. The GeneXpert ® HIV-1 159 Qual is a molecular cartridge-based assay that detects total nucleic acid (DNA and RNA) and 160 provides a qualitative result (HIV detectable or undetectable) [23]. As such, the GeneXpert HIV 161 Qual cartridge was labeled with the identification collected blood sample. Then after it was 162 opened and 750 µl of sample reagent was transferred in using provided /inserted pipette in the 163 kit. Mix the whole blood as well by inverting the EDTA tube containing such blood at least 164 seven times. About 100µl whole blood was transferred immediately using provided pipette in the 165 kit or calibrated automatic pipette in to same sample chamber of GeneXpert HIV Qual cartridge 166 soon after the lid was firmly closed. Finally, the prepared GeneXpert HIV Qual cartridge was run 167 by starting the test on GeneXpert machine and interpreted the result output as “HIV-1 detected” 168 or “HIV-1not detected” after 90 minutes [24]. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 9 169 Cluster of differentiation at 4 (CD4) Count 170 Maternal CD4 was counted using FACS Presto Machine after incubating one drop (40µl) out of 171 collected 5ml maternal blood for viral load samples on CD4 cartridge for 18 Minute. Then, 172 assess its association with HIV infection among exposed infants. 173 Maternal Viral Load determination 174 5ml of whole blood was collected from mother with EDTA K3 plasma separating tube (PPT), 175 wait for 4–12hoursand then centrifuged at 3000 rpm for 3minute to separate the 1-2ml 176 plasma from red blood cells. Such separated plasma was stored at 2-8 oCfor a week due to 177 not done immediately. After then, it was transported to Debre Markos Comprehensive 178 specialized hospital, Molecular biology laboratory at 2-8 oC with triple packaging system to 179 determine maternal viral load. Finally, the viral load level was determined by PCR 180 technique(Roche Diagnostics GmbH, Mannheim, Germany), the high or low viral load results 181 were recorded and assessed its association with HIV infection to infants. 182 Quality control 183 The structured questionnaires were prepared in English and translated into Amharic language 184 and then back translated to English to check inconsistencies of meaning of words. About 9 (5%) 185 of structured questionnaire was pretested in Motta health center and training was also provided to 186 one BSc midwifery how to collect the socio-demographic and clinical data. The expired date on 187 the GeneXpert HIV-1Qual cartridges was cheeked and the GeneXpert system machine (Cepheid) 188 was calibrated annual regularly. Quality control for CD4 was also done and printed out daily 189 soon after start up the FACS Presto CD4 Machine and it was cross checked with its standard 190 reference ranges. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 10 191 Data analysis 192 Data was entered by EpiData version 3.1 and data analysis was performed using statistical 193 package for social sciences (SPSS) version 20. The prevalence of HIV-1 was determined by 194 descriptive statistics. Multivariable logistic regression was done by entering the variables with 195 p < 0.2 in the bivariable logistic regression to identify the factors associated with HIV-1 196 infection among exposed infants by considering the P value < 0.05 as a statistically significant 197 association. 198 Ethical Consideration 199 Ethical clearance and permission letter were obtained from Shegaw Motta General Hospital 200 administrative office with reference number (SMGH 534/94/72). Additionally, written consent 201 was obtained from a parent and/or legal guardian of study participants in accordance with the 202 Declaration of Helsinki. Furthermore, the participation of study participants was entirely 203 volunteer based on parents and/or legal guardian and their confidentiality was kept by coding 204 rather than naming for identification. Finally, all HIV positive infants were linked to ART 205 clinic at this hospital for further management. 206 Operational definitions 207 GeneXpert HIV-1 Qual assays: GeneXpert® Instrument Systems, is a qualitative in vitro 208 diagnostic test designed to detect human immunodeficiency virus Type 1 (HIV-1) total nucleic 209 acids using human venous whole blood and capillary from individuals suspected of HIV-1 210 infection for infant. 211 Infant: infants or babies whose age less than 12 months and cannot produce their own serological 212 detectable antibodies against HIV. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 11 213 HIV1 exposed infants: The infants who born from HIV positive mother or women. 214 Results 215 Socio-demographic characteristics of study participants 216 A total of 155 infants were recruited to the current study from which almost more than half of 217 infants 79(50.9%) were females and the rest males. Furthermore, the majority of 87(56.1%), 218 87(56.1%), 123 (79.4%), 138(89.0%) and 148(95.5%) infants were born from mothers who 219 could not able to write and read, urban residence, self-employed, ages range from 25-34years 220 and married mother, respectively. About 90 (58.1%) infants were less than 6 months in their age 221 and the rest 65 (41.9%) was 6- 12months in the current study (Table: 1). 222 Table 1: Socio-demographic characteristics of study participants at Shegaw Motta General 223 Hospital, 2023 Variable Categories Frequency Percent (%) Gender of infant Male Female 76 79 49.1 50.9 Residence Urban Rural 87 68 56.1 43.9 Maternal education Unable to read and write Primary & above 87 68 56.1 43.9 Maternal age (in years) < 25 25–34 ≥35 6 138 11 3.9 89.0 7.1 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 12 Maternal marital status Not married Married 7 148 4.5 95.5 Maternal occupation Housewife Government employee Self-employed 24 8 123 15.4 5.2 79.4 Infant age (in months) <6 months 6- 12months 90 65 58.1 41.9 224 225 226 227 Prevalence HIV 1 among exposed infants 228 One hundred fifty-seven HIV-exposed infants were tested for HIV infection by GenXpert HIV1 229 Qual assay (EID). This study revealed that the overall prevalence of HIV1 infection among 230 exposed infants was 6 (3.87%) with 95% CI; 2.9 - 8.2 in the current study ( Fig 1). 231 Factors Associated with HIV1 infection among exposed infants 232 According to bivariable analysis, residence, maternal education level, antenatal care (ANC) 233 follow up, maternal Antiretroviral therapy (ART) enrolment, place of delivery, infant’s age at 234 enrollment, attendant of delivery, maternal Antiretroviral (ARV) prophylaxis, infant nevirapine 235 (NVP) prophylaxis, maternal CD4+ (cell/mm3) and maternal viral load (p-value < 0.2) were 236 entered to multivariable logistic regression analysis. Regarding to multivariable logistic 237 regression analysis, pregnant women had not ANC follow up (AOR=7.281, 95% CI: 2.53- 238 20.96: P = 0.001), home delivery ( AOR = 3.239, 95% CI: (1.75-9.19, P= 0.001), maternal not . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 13 239 received ARV prophylaxis (AOR = 9.213, 95% CI: 2.95-10.11, P = 0.001) , infant not intake 240 NVP prophylaxis ( AOR = 2.560, 95% CI: 1.98-10.24, P = 0.007) and maternal high viral load 241 (>1000 copies) ( AOR = 5.120, 95% CI: 2.75-11.18, P = 0.004) during pregnancy were the 242 identified factors significantly associated with HIV infection among infants born to HIV 243 positive mothers. As the result, infants born to HIV positive mother who had not ANC follow 244 up, home delivery, maternal not received ARV prophylaxis, infant not intake NVP prophylaxis 245 and maternal high viral load (>1000 copies) were 7.281, 3.239, 9.213, 2.560 and 5.120 times 246 more likely to be infected by HIV in this study, respectively (Table 2). 247 Table 2: Bivariable and multivariable logistic regression analysis of factors associated with 248 HIV1 infection among exposed infants at Shegaw Motta General Hospital Town, Ethiopia, 2023 HIV1 Variables Categories Positive N (%) Negative N(%) COR(95%CI) P value AOR(95%CI) P value Gender of infant Male Female 2(2.6) 4(5.4) 74(97.4) 71(94.6) 1 2.324(0.69-5.61)0.720 Infant age (in months) <6 months 6- 12months 6 (6.7) 0(0) 84 (93.3) 65 (100) 1.653(0.812-7.921)0.431 1 Residence Urban Rural 4(3.4) 2(2.9) 83(96.6) 66(97.1) 1 3.12 (1.45-5.11)0.102* 1 2.51(0.69-4.67) 0.145 Maternal education Unable read and write Primary & above 3(3.4) 3(4.5) 85(96.6) 64(95.5) 1.78(2.14-4.76)0.019* 1 3.16(0.43-5.89) 1 0.205 Maternal age (in years) < 25 25–34 ≥ 35 0 (0) 4 (3.0) 2 (18.2) 6 (100) 131 (97.0) 9 (81.8) 1 0.729(0.31-1.73)0.473 1.545(0.47-5.12)0.478 Maternal marital status Not married Married 1(14.3) 5 (3.4) 6(85.7) 143(96.6) 1 1.714(0.72-4.11)0.427 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 14 249 Key:* = variables entered to multivariate regression (P- value < 0.2),** = statistical significant association ;ANC: Antenatal care; 250 AOR: Adjusted odd ratio; ART: antiretroviral therapy; ARV: Anti-retroviral; CD4- cluster of differentiation -4 ; CI: confidence 251 interval ,COR: crude odd ratio: EBF: exclusive breast feeding ; HIV: human immunodeficiency, MF: mixed feeding; NVP: 252 Nevirapine , TBA: Traditional birth attendant Maternal occupation Housewife Self-employed Government employee 2(8.3) 3 (2.5) 1(12.5) 22 (91.7) 120 (97.5) 7(87.5) 0.857(0.31-2.43) 0.367 1.6490.418-3.24) 0.771 1 ANC follow up Yes No 2 (2.7) 4 (5.0) 73 (97.3) 76 (95.0) 1 10.615(4.40-25.61)0.001* 1 7.281(2.53-20.96) 0.001** Maternal ART enrolment Enrolled Not enrolled 2 (1.5) 4 (23.3) 135 (98.5) 14 (77.7) 1 16.179(4.58-57.22)0.001* 1 6.985(0.61-28.91) 0.195 Place of delivery Home Health facility 2(3.9) 4 (3.8) 49 (96.1) 100(96.2) 4.681(1.78-12.29) 0.002* 1 3.239(1.75-9.19) 1 0.001** Infant Feeding pattern EBF ERF MF 0(0) 2(3.8) 4(5.0) 23(100) 50(96.2) 76(95.0) 1 2.857(0.91-4.43) 0.367 1.649(0.518-8.24) 0.571 Infant’s age at enrollment ≤ 6 weeks >6 weeks 2(2.0) 4 (7.6) 100(98.0) 49 (92.4) 1 4.681(1.78-12.29) 0.002* 1 5.219(0.65-14.29) 0.327 Maternal ARV intervention Before delivery During/after delivery No 1(2.6) 2(2.2) 3 (11.1) 38(97.4) 87(97.8) 24(88.9 1 1.857 (0.31-6.43) 0.367 4.649(0.418-7.24) 0.771 Attendant of delivery TBA Skilled delivery 3(2.9) 3 (5.7) 99(97.1) 50 (94.3) 4.381(1.68-11.29) 0.001* 1 4.239(0.75-9.19) 1 0.512 Maternal ARV prophylaxis Not Received Received 4(11.1) 2(1.7) 32(88.9) 117 (98.3) 5.418(2.37-12.41) 0.001* 1 9.213(2.95-10.11) 1 0.001** Infant NVP prophylaxis Yes No 2(2.2) 4(6.4) 90(97.8) 59(93.6) 1 4.681(1.78-12.29) 0.002* 1 2.560(1.98-10.24) 0.007** Maternal CD4+ (cell/mm3) < 200 ≥ 200 5(31.2) 1(0.7) 11(68.8) 138 (99.3) 1 5.418(2.37-12.41) 0.001* 1 9.213(0.95-10.11) 0.354 Maternal viral load <1000copies (Low) ≥ 1000 copies)(High) 2(1.4) 4 (28.6) 139(98.6) 10(71.4) 1 4.681(1.78-12.29) 0.002* 5.120(2.75-11.18) 0.004** . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 15 253 Discussion 254 The prevalence of HIV1 infection on infants born from HIV positive mothers in the current study 255 was 3.87%. This finding was in line with studies conducted in varies part of Ethiopia like in 256 Dessie Town Public Health Facilities 3.8% [25], Pastoralist Health Facilities, South Omo Zone 257 5.3% [26], East and West Gojjam Zone5.9% [27] and University of Gondar Specialized Hospital 258 5.5% [28], east Africa 7.68% (29)and Kenya 3.3% [30]. 259 The current prevalence of HIV1 infection was lower than 11.4% pooled prevalence in Ethiopia 260 [19], 9% in Sidama [31], 10.1% in Amhara Region [32] and 9.9% in Bahir Dar city public health 261 facilities [33]. This difference might be due to the variation of ART and PMCT follow up, 262 awareness to HIV, policies, and strategies on HIV control and prevention, methodology and 263 sample size. In contrast, it was slightly higher than 1.5%, 1.6%, 2.7%, and2.1%, compared to the 264 study conducted in France [34], Ukraine [35], Rwanda[36] and Tigray regional state, Northern 265 Ethiopia [37], respectively. This difference might be due to high coverage of PMTCT 266 interventions in developed countries and limited access, lack of awareness, poor quality of 267 service in developing countries including Ethiopia. 268 Regarding to multivariable logistic regression analysis in the current study, mothers had not 269 ANC follow up(AOR=7.281, 95% CI: 2.53-20.96: P = 0.001)was significantly associated with 270 MTCT ofHIV1. Meanwhile, mothers who did not attend ANC follow up were 7.281 times more 271 likely to transmit the virus to their infants than mothers who had ANC visit. This finding was 272 agreed with the study conducted in Rwanda [38], Ethiopia[ 39], Gondar city health institutions, 273 Northwest Ethiopia[40]and public health facilities in Dessie town [41].Similarly, home delivery 274 (AOR = 3.239, 95% CI: (1.75-9.19, P= 0.001)was also a factor significantly associated with . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 16 275 MTCT of HIV1 infection. Thus, infants born at home had a 3.239 times greater chance of 276 contracting the virus than those born in health facilities. This finding was concordant with the 277 study illustrated in East Africa [42], rural Uganda [43], South west Ethiopia [44], Dire Dawa 278 [45], southern Ethiopia [46], Northwest Ethiopia [47], Gondar city health institutions [40],South 279 Gondar zone [48]and Bahir Dar administration(49).This might be due to HIV testing for 280 mothers with unknown HIV status who delivered at health facility and immediate ARV 281 intervention for mothers and their infants if the test was positive. In addition, safe delivery 282 practice and appropriate post-natal care during health facility delivery might support this 283 significant association. 284 On the other hand, absence of maternal intake ARV prophylaxis(AOR = 9.213, 95% CI: 2.95- 285 10.11, P = 0.001) was 9.213 times more likely to born HIV positive infants compared to those 286 received ARV prophylaxis. A finding was in line with studies conducted in Vietnam[50],East 287 Africa [ 42],Uganda[43], Northwest Ethiopia[47],Ethiopia such as Mekele city [51], health 288 facilities of North Wollo Zone [52], Bahir Dar administration[49]. This might be as a result of 289 maternal ARV drug intake causing the reduction of maternal viral load and reduced risk of viral 290 transmission to their infants. Furthermore, infants not intake NVP prophylaxis (AOR = 2.560, 291 95% CI: 1.98-10.24, P = 0.007)were2.560times more likely to be HIV positive as compared to 292 infants received NVP prophylaxis at birth according to this study. Such findings were agreed 293 with the previous studies reported in Brazil [53], Uganda (54), Dire Dawa [45], southern 294 Ethiopia [55] and Ethiopian Public Health Institute [56, 57]. This might be due to the viral 295 suppression effect of NVP, which is a non-nucleoside reverse transcriptase inhibitor, by binding 296 to reverse transcriptase, thereby blocking RNA and DNA dependent DNA polymerase actions 297 including HIV replication. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 17 298 Finally, maternal high viral load (>1000 copies ) (AOR = 5.120, 95% CI: 2.75-11.18, P = 0.004) 299 during pregnancy were the factors significantly associated with HIV infection among exposed 300 infants by which infants from high maternal viral load were 5.120times more likely to be 301 infected by HIV than infants born from low maternal viral load. The findings were concordant 302 with a study carried out in India [ 58], Philadelphia [59], Uganda (54), Rwanda [38], Gaza 303 Province—Mozambique (60), northeast South Africa [61]. This might be due to high viral load 304 concentration could compromise the maternal immune system and leads to vertical 305 transmission of HIV to infants. 306 Conclusion 307 The prevalence of HIV1 infection among exposed infants born to HIV positive mothers was still 308 high (3.87%). Pregnant women had not ANC visits , home delivery, Absence of ARV 309 prophylaxis, infants not intake NVP prophylaxis, and maternal high viral load increases HIV 310 infection among exposed infants. Therefore, health facilities should strictly strengthen the 311 PMTCT service by providing maternal ARV prophylaxis, infant NVP prophylaxis, promote 312 ANC service, early screening maternal viral load and scale up skilled delivery to eliminate 313 HIV infection among exposed infants. 314 Abbreviations 315 AOR–adjusted odd ratio, ART- Antiretroviral therapy, ARV-antiretroviral , ANC-Antenatal 316 Care, COR- Crude odd ratio, DNA- Deoxy-ribose nucleicacid, EDTA- ethylenediamine tetra 317 acetylene, EID- early infant diagnosis, HIV- Human immunodeficiency virus, NAAT- nucleic . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprintthis version posted September 2, 2024. ; https://doi.org/10.1101/2024.09.01.24312902doi: medRxiv preprint 18 318 acid amplification, NVP-nevirapine, PCR- polymerase chain reaction, PMTCT - prevention of 319 mother- to child transmission, MTCT- mother to child transmission, RNA- ribose nucleic acid 320 Acknowledgments 321 The authors would like to thank administration of Shegaw Motta General Hospital for providing 322 a permission to conduct this study. By the next, we would like to acknowledge Molecular 323 biology laboratory of Debre Markos comprehensive specialized hospital (DMCSH) including its 324 laboratory staffs that did the viral load of referred plasma sample. We would also like to thank all 325 laboratory staffs in this hospital, study participants, and data collectors for their unreserved 326 efforts and willingness to participate in this study. 327 Authors Contribution 328 Conceptualization: Destaw Kebede Nigusie, Fantahun Getaneh Damitew, 329 Data curation: Fantahun Getaneh Damitew, Kirubel Endalamaw Melsew 330 Formal analysis: Destaw Kebede Nigusie, Melsew , Girma Zerefaw, Abebe Fenta Nigusie : 331 Investigation: Destaw Kebede Nigusie, Fantahun Getaneh Damitew, Kirubel Endalamaw 332 Melsew , Girma Zerefaw, Abebe Fenta Nigusie 333 Methodology: Kirubel Endalamaw Melsew, Girma Zerefaw, Abebe Fenta Nigusie 334 Resources: Destaw Kebede Nigusie and Fantahun Getaneh Damitew 335 Supervision:, Girma Zerefaw Abay, and Abebe Fenta Nigusie 336 Visualization: Fantahun Getaneh Damitew, Kirubel Endalamaw 337 Writing – Original Draft Preparation: Destaw Kebede Nigusie, Fantahun Getaneh Damitew, 338 Writing – Review & Editing: Girma Zerefaw Abay, and Abebe Fenta Nigusie . 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