Introduction
In 2022, an estimated 1.2 million pregnant women worldwide were living with HIV, among those approximately 82% of them receiving antiretroviral medication to prevent mother-to-child transmission (MTCT).1 Since 2000, interventions targeting the vertical transmission of HIV during pregnancy, childbirth and breast feeding prevented an estimated 3.4 million infections among children aged 0–14 years.2
HIV testing and counselling (HTC) is critical to ensuring universal access to HIV prevention and care services. HTC is likely to increase the life expectancy of individuals with HIV, and it is a cost-effective intervention.3 In high-income countries, MTCT of HIV/AIDS is nearly zero with the help of safe and clean delivery services, safe breastfeeding practices (eg, exclusive breast feeding for the first 6 months), access to antiretroviral therapy (ART) and effective testing and counselling for HIV.4 Between 2009 and 2013, the MTCT rate dropped from 28% to 18% in Sub-Saharan Africa (SSA).5 Even though the MTCT rate has a positive trend, it is considerably higher than elsewhere. However, despite current progress, SSA still has a high burden of MTCT.6
The joint United Nations Programme on HIV/AIDS sets the global 90-90-90 target to ensure that 90% of people living with HIV know their status, 90% of people living with HIV start ART, and 90% of people with ART have suppressed viral load by 2020. The strategy was designed to eliminate HIV/AIDS epidemics by 2030.7 The WHO promotes a comprehensive approach to improve the effective prevention of MTCT of HIV.8 The approach includes routine HTC for pregnant women during antenatal care (ANC), clinical management and highly active ART for the mother or antiretroviral (ARV) prophylaxis during labour, and counselling on safe infant feeding practice after delivery.8 9 Prevention of Mother to Child Transmissions (PMTCT) of HIV/AIDS is an integral part of routine ANC care to ensure a high rate of case detection and timely treatment coverage.10 11 The WHO recommends provider-initiated HTC as a routine component of the ANC package for all women in all ANC settings. Those who test positive will be linked immediately with interventions such as HIV treatment for the PMTCT.12 Improving the quality of PMTCT services could substantially contribute to reducing the burden of HIV in children.13
Around 76% of early infant mortality and 75% of HIV progression could be reduced by early HIV diagnosis and early ART.14 Regarding closing that gap, poor adherence to therapy, poor mother-to-child linkage to prevention in MTCT services, low early infant diagnosis coverage and low paediatric ART coverage are among the main challenges in SSA.5 15 In Ethiopia, only one in five (19%) women received HIV counselling and testing during ANC visits in 2016, ranging from the highest coverage in Addis Ababa (95.8%) to the lowest in the Somali region (14.2%).16
The WHO states that MTCT is a serious public health problem that is attributable to 90% of childhood HIV infections.17 18 Globally, there were an estimated 160 000 children with newly acquired HIV in 2021. Although children accounted for 4% of people living with HIV, they accounted for 15% of all AIDS-related deaths19 as they have low immunity, which makes them vulnerable to opportunistic infections.14 Over 90% of HIV infections among children occur during pregnancy, labour/delivery or breast feeding.8 More than 80% of new HIV infections are from SSA countries. Nearly 95% of children with HIV infection in Ethiopia are attributed to MTCT.20 21
Despite notable improvements in HIV care, the challenges that affect the effectiveness of preventing MTCT of HIV are diverse and multi-factorial.22 23 Previous studies identified socio-demographic characteristics such as marital status, education level, place of residence, wealth status, risky sexual activity, having a stigmatising attitude, knowledge of HIV/AIDS and knowledge of MTCT during pregnancy as being factors that affect HIV testing among pregnant women.24–26 In addition, health system-related factors influence the uptake of effective HIV counselling and testing during pregnancy.27 28
Tanahashi showed five health service coverage measures. These are (1) availability coverage, (2) accessibility coverage, (3) acceptability coverage, (4) contact coverage and (5) effective coverage.29 Of these coverage measures, the ‘contact coverage’, also known as actual coverage, measures the fraction of participants who used a service. However, this does not guarantee the success of an intervention since it does not account for the quality of care provided to patients.29–31 ‘Effective coverage’, which measures both utilisation and quality of care estimating potential health gains from using the services, has been identified as a preferred measure of coverage.32
Ethiopia has a low effective coverage of ANC services (22%), with regional variations from 15% in the Somali region to 39% in the Tigray region.32 Moreover, the contact coverage of HIV testing during ANC follow-up has been explored in a previous study.24 The effective coverage of HTC services remains unexamined. This study fills that gap by assessing the effective coverage of HTC during ANC follow-up in Ethiopia using a geographic data linkage of the Ethiopian Demographic Health Survey (EDHS) and Ethiopian Service Provision Assessment (ESPA) datasets.