As per the searching trail of investigators, there is no study merely studied on outcomes of HIV exposed infants after the starting of option B+ program in Amhara region. This study tries to evaluate the effectiveness of the program using the already collected database of the referral hospitals in Amhara region. Consequently, the finding got the incidence rate of HIV transmission during the follow up period in Amhara regional state referral hospitals as 2.3% (95% CI, 0.5–4.6%) at the time of enrollment or first DNA-PCR test, and 3.7% (95% CI, 1.4–6.5) at the time of completing PMTCT program using antibody or DNA-PCR test.
While the finding of this study compared with a study that was considered option A PMTCT programme, and option B+ PMTCT program in Uganda. That study reported the rate of transmission as 5.1% in option A PMTCT programme, and 4.3% in option B+ PMTCT program (40). These two researches were in line in option B+ PMTCT programme, but the current study has a lower rate of transmission than that of option A PMTCT programme (40). The difference could be because of health care shift. According to WHO recommendation option B+ PMTCT program have a better outcome in preventing HIV transmission than option A PMTCT program (4).
The finding of this study was higher than a stud done in Bishoftu hospital that reported a zero rate of MTCT after option B+ PMTCT programme (47). The first difference might be because of the quality of health care service, particularly PMTCT, delivered in the study hospitals. Even if both of the studies considered option B+. The second difference might be because of study settings. This study was studied in 5 hospitals, which increase the probability of infection, but the referenced study was conducted in one hospital. This study was also in line with the overall rate of HIV transmission in Bishoftu hospital 4.3 % at the age of 6–8 weeks (47). The Bishoftu hospital’s study was conducted in considering both option A and B+ PMTCT programme. Consequently, the study reported the overall rate of HIV transmission, and each option rate of transmission. The similarity mighty be because of methodological effluence. The current study considered five hospitals and address each hospital than the referenced one, which was conducted in one hospital. The finding was agreed with a study done in South Africa that reported MTCT rate as 1.3% in 2014 (48). It was also in line with a study that reported the rate of HIV transmission as 2.2% in Cameroon, which was a retrospective, cross-sectional study over a period of four years from 2013–2017 (49). The similarity might be because of similar socio-demographic status as all were from Africa, and utilization of one guideline as per WHO recommendation, option B+ PMTCT program (4). But this finding had a lower rate of HIV transmission than a study from similar setting, Cameroon, that was 22% (50). This difference might be because of different PMTCT guideline implementation. This study used the new version of PMTCT, option B+, but the referred study was not used the new version. The finding was also agreed with a study done in Southern Ethiopia (4.2%) (51). This similarity might be because of implementing one guideline as per WHO recommendation, option B+ PMTCT program (4).
The observed rate of MTCT of HIV was comparable to the rate in developed countries 2% (52,53). This similarity might be due to advanced health care service such as screening equipment, and medications used in developed countries.
In relative to most of the studies, this study was reported a lower rate of HIV transmission. All the studies that done in southwest Ethiopia 17% (41), done at national level in 2012, 17% (54), done in Dire Dawa city 15.7% (55) and done in East and West Gojjam Zones 18 (5.9%) (20) reported a higher rate of HIV transmission. The finding of this study was also lower than a study done in South Gondar, Northwest Ethiopia (10.1%), Southwest Ethiopia (9.6%), Gondar University Hospital 10% (18, 19, 56). The difference could be because of a difference in quality of health care service provided, and study period difference. All those studies were conducted before 2012, before starting option B+. The rate of transmission in this study was lower than a study done in Johannesburg, south Africa study which was 12 (5.2 %) (57). This difference might be because of implementing old version guideline in South Africa as the study was conducted in 2007, before the introduction of option B+ PMTCT program.
Indeed, there are evidences that showed a reduced rate of mother to child transmission of HIV in Ethiopia from 5.9% (20), 10.1% (18), 9,6% (19), 10% (56) to 2.3% at this study. This could be because of PMTCT strategy that might had contributed to the reduction of the MTCT of HIV. This progress had a support from a study done in Zambia and Malawi (58, 59). But it was not going on as expected, since, the strategy of Ethiopia for elimination of vertical HIV transmission was to get it below 2% at 2015 (60).
In this study childhood malnutrition (P = 0.003), home delivery (P = 0.034), and incomplete immunization status (P = 0.000) were associated with HIV infection.
Although, none of the variables were not be found to be independent predictors of HIV infection using logistic regression as the data failed to pass the assumption of logistic regression. But on chi-square test, home delivery was associated with HIV infection. This was in line with a study that identified home delivery as having association with HIV infection at 6–8 weeks (47, 55, 56). This might be due to the increased risk of HIV transmission during labour as it is not assisted by professionals. In this study children who did not receive cotrimoxazole for children was had an association with HIV transmission. This agreed with a study (55). Some studies reported rural residence (55, 56, 61), and mixed feeding (28, 62) as having association with HIV transmission. But both of these variables had no association with HIV transmission in this study. In addition, mothers on late AIDS stage, and mothers that had not follow up of ANC were had association with increased risk of mother to child HIV transmission (41, 19). This is also contradicting with this study. This study reported as those variables had no association with HIV infection.
The rate of LTFU is discussed in considering both quantitative and qualitative findings. As the interest of investigators, reporting both qualitative and quantitative data frequently might give a clear description for the audience about LTFU. The incidence of LTFU in Amhara regional state referral hospitals was 8.8% (95% CI, 5.4–12.4%). This was lower than a study in Ethiopia at national level that 89.4% of the HIV positive women were loss to follow up (63). The other study in Ethiopia were also reported 48% mother-infant pairs of LTFU by 6 weeks postnatally (39). This study was lower than a study in Ethiopia at national level that 95.9% of HIV-infected women were lost to follow up by delivery (64). This might be because of study period and population difference. This finding was produced in considering only women who were admitted to PMTCT either at pregnancy, delivery or postnatally and had at least one DNA-PCR at 6 weeks or before or latter. But the referenced papers studied among HIV positive women without restricting to PMTCT services. The other was the study time. Almost all the above referred papers studied before 5 years in average. Within these 5 years, there were many changes on the socio-demographic status, and health care services.
While the LTFU was compared with some of African countries, the finding of this study was lower than a study in Mali that LTFU was 53% (65), in South Africa that LTFU was 40.4%) (25, 66), in Kenya that LTFU was 27.4% (67), in Malawi that LTFU was 82% (68), and a study done in Brazil was 15.4% (69). This might be due to a difference in study time. Almost all the above referred papers studied before 6 years in average. Within these 6 years, there were many changes on the socio-demographic status, and health care services across these African countries as per WHO recommendation.
The rate of LTFU in this study was also lower than a study that compared Option A and B+ in Uganda. The report was 30.3%, and 28.4% respectively (40). The difference might be because of socio-demographic difference, or design difference. The current study was done using data retrospectively, whereas the referred paper studied prospectively. The finding was lower than that of a study done in northwest Ethiopia, Woliso 39.4% (19), and a study done in Bishofitu Hospital, the rate of LTFU was 22.2 % (47). These all were because of either study period difference or difference in types of guidelines implemented in PMTCT department. In this study rural residence (P = 0.003), incomplete immunization status of children (P = 0.004), maternal advanced AIDS status (stage 3 and 4) (P = 0.00), and home delivery (P = 0.005) were associated with LTFU. A study in brazil also reported that rural residence was associated with LTFU (69). This might be because of the sterility of the procedure while birth attendants assist the labour in home. In addition, a child who born in home did not get prophylaxis.
In the in-depth interview section lack of commitment, and negative attitude of health professionals for PMTCT program utilizers were mentioned as main contributors of LTFU. The commitment of professionals that works in PMTCT were critical for effective PMTCT completion. This is similar with the opinions of Nurses that feel their education and commitment was instrumental in the success of the PMTCT programme from a study in south Africa (70). On the other hand, lack of PMTCT service providers, shortages and interrupted supplies of medications were also mentioned as contributors of LTFU. Shortage of medications at each health center had similar consequences with the study reported by Rujumba et al (71). The interviewee mentioned that some of the health centers at times lacked Nevirapine for the mothers and their babies referred clients to other ART centers. This brought some inconvenience to patients as most of them did not have money for transport to get them to the other site and thus they could have ended up not getting there and will not come back because of discontinuing in the last visit. Rujumba et al were also mentioned that for proper running of the PMTCT programme appropriate number of health care workers were needed (71).
Fear of family response, and anticipated ignorance, fear of isolation, and blaming were mentioned under the psychosocial influencers of LTFU. A study by Doherty et al reported that some mothers decided to move the formula milk and place it in other containers which were not of its origin because of fearing discrimination (72).
Beyond these, poverty, and lack of paternal support were also raised as issues for LTFU. This was agreed with a study conducted in 2015 in the University Teaching Hospital, PMTCT center. The study identified poverty, stigmatization, low involvement of the partners, and misunderstanding of the PMTCT as factors reducing the adherence rate, and contributed for LTFU (73).
The alternatives mentioned by participants to prevent LTFU were networking with HEWs, involving family members, and admitted to civic societies. There was an evidence that partners in Health has demonstrated a successful model of promoting adherence to HIV medications by using paid community health workers who visit each patient at home in Ukraine (52). Family, particularly husband involvement in the PMTCT services was stated as having a better result on the outcomes of such programmes. This was agreed with the UNAIDS’s report that showed men involvement in the PMTCT programme improve the outcomes of PMTCT programme (74).
When there was loss to follow up; phone-based communication, group-based communication, and addressing lost clients through the contact person were the stated options to retained the clients to the program as described by interviewee. Researches also explained that programs that involved community members in developing, implementing, and monitoring activities were more likely to be acceptable to the community and to had more eﬀective outcome (66, 67).
The other descriptions to increase health seeking behavior of clients, and decrease LTFU were improving quality of counseling, increasing ART sites, increasing drug accessibility, improving ethical and professionalism practice of professionals, and supply child friendly dosages. Since education empowers the woman to have autonomy in making important decisions without relying on other people, proper counseling would decrease LTFU (51, 53).
On the prevention and tracking mechanism of LTFU section; interviewees focused on health facilities, health professionals, and civic societies active involvement for the future. The health facilities that provide ART care should be increased in number, and all ART center should increase the availability of drugs.
In addition, training for professionals on counseling, and respectful care need to be given frequently. Training for PMTCT program providers may be necessary in improving the interaction skills.
A study from Thailand reported success in PMTCT services by providing training for staﬀs on a periodic basis (54). Another study by Rujumba et al were mentioned that proper running of the PMTCT programme needed not only the number of health care workers, but also as long as they have been involved in delivering services, they must obtain adequate training in order to update their knowledge and skills (71). Most of participants agreed that incorporating clients to civic society to improve their drug adherence andquality of life to be implemented in the future. A home visit from social group can play an important role in improving follow up of PMTCT clients. A study from rural Bangladesh found that home visits reduce rates of LTFU in PMTCT (62).
The rate of mortality is discussed in considering both quantitative and qualitative findings. As the interest of investigators, reporting both qualitative and quantitative data frequently might give a clear description for the audience regarding mortality.
The incidence of child mortality after enrollment to the PMTCT program were zero. This study had a lower result than a study done in Uganda that report 19% rate of mortality in 2006 (75). The difference might be because of guideline difference. The current study included mother-child pairs, who were treated under the new version, option B+. But the referred paper study under the old version, option A. These two guidelines have different outcomes in all of PMTCT variables, HIV transmission, mortality, and LTFU. In any situation the new version has better outcome. This study has also a lower result than a study that compared Option A, and option B+ programmes. The referred paper reported 0.9% and 1.4% in option A and option B+ respectively (40). The difference might be because of study period difference. The current study was conducted from January 01/2014 and May 30/2017 but the referred paper considers from 2010–2011 for option A, and from 2013–2014 for option B+. In addition, the referred paper used a large sample size, included all children. That was 2203 for option A and 1571 for option B+.
The majority of interviewee mentioned HIV transmission was a flaring for mortality. As the explanation of interviewee, this could be due to the progress of the infection to advanced stage, which is a hallmark for mortality. The others interviewee mentioned carelessness of parents to feed their child cause mortality. A child who was not feed timely would be developed undernutrition. According to Ethiopia context, malnutrition is among the top leading causes of child mortality.
Poor socioeconomic status was also mentioned to be one ground of mortality. Mothers from poor socioeconomic household would be fail to care their growing child and themselves.
The lack of care for the child and mothers would expose them for illness mainly infectious and childhood diseases.
On the prevention of mortality section, the interviewee mentioned implementation of option B+ appropriately, screen the child frequently for possible childhood diseases, follow all the enrolled children up to the end of PMTCT programme, teaching danger signs of childhood illness, and improve nutritional status of both the infants and mothers were mentioned by most interviewee.