The Impact of Ethiopia’s Program on Reducing Mother-to-Child HIV Transmission

BY RADIATE FASIL & FADHINA PETIT-CLAIR

Introduction

Mother-to-child transmission (MTCT) of HIV remains a significant global health challenge. MTCT can occur during pregnancy, labor, delivery, and breastfeeding, and over 90% of children with HIV are believed to have contracted the disease through one of these routes. Without breastfeeding, MTCT occurs in 15–30% of cases; however, breastfeeding into the second year of life is believed to increase the risk of infection by an estimated 45%.⁴ 

Sub-Saharan Africa continues to carry a disproportionate global burden, accounting for approximately 68% of all people living with HIV. In Ethiopia, an estimated 612,925 individuals are living with HIV, with the highest prevalence recorded in the Gambella region (4.8%) and in Addis Ababa (3.4%).⁴ 

Organizations, including the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO), have prioritized efforts to eliminate MTCT, with interventions such as prevention of mother-to-child transmission (PMTCT) and antiretroviral therapy (ART) contributing to significant global declines in pediatric HIV.⁴ PMTCT efforts worldwide have prevented an estimated 1.4 million childhood infections.⁴

Ethiopia launched its PMTCT program in 2001 and subsequently revised national guidelines in 2007, 2011, and 2013 to align with WHO recommendations, including Option B+.⁶ Under Option B+, women begin lifelong ART immediately upon HIV diagnosis—regardless of their CD4 cell count—most commonly through a fixed-dose combination of the medications TDF/3TC/EFV.⁶ Option B+ has contributed not only to reductions in mother-to-child transmission (vertical transmission) but also in sexual transmission (horizontal transmission) among partners.⁶ 

Key implementing partners include the Ethiopian Ministry of Health, major funders such as the President’s Emergency Plan for AIDS Relief (PEPFAR), which has invested nearly $1.2 billion and supported more than 325,000 health workers across Africa,¹⁰^, ¹¹ and policy partners including UNAIDS and WHO.⁹ NGOs additionally support community outreach, service delivery, and health promotion.¹³

Funding sources include domestic government support and international donors, such as WHO, UNAIDS, and PEPFAR, with the Ethiopian government remaining a major contributor to sustain the program.^9,11,12,18 Ethiopia’s motivation stemmed from high pediatric HIV incidence and the global movement toward eliminating MTCT.⁸ Strengthening maternal and child health services and integrating HIV prevention into existing care frameworks were further drivers.¹ 

Although implementation initially faced challenges—including limited community acceptance and low service coverage—Ethiopia incorporated WHO’s global recommendations and drew lessons from successful international models such as Botswana, which achieved greater than 95% PMTCT coverage by 2013.¹³ Despite progress, barriers persist, including limited access to HIV and prenatal care, especially in rural areas, cultural stigma discouraging HIV testing and treatment, inadequate workforce capacity, low male-partner involvement, and persistent gaps in resource availability.⁵

Population, Intervention, Outcomes of Interest, and Time Period

This case study centers on healthcare professionals involved in implementing PMTCT services, given their role in facilitating HIV prevention efforts. The study covers the period from 2001 to the present, with particular focus on 2007, 2011, and 2013 – years that marked major policy realignments in accordance with the evolving WHO guidelines.¹⁵ This timeline enables an assessment of the program’s long-term effects, highlighting both successes and persistent challenges that affect maternal and child health outcomes, specifically in reducing MTCT.

Ethiopia’s PMTCT program has undergone many revisions to align with evolving global guidelines.¹ There are several key components to Ethiopia’s PMTCT program: HIV testing, early infant diagnosis, and follow-up care for exposed infants to improve health outcomes.² The outcomes of interest for this intervention include: reductions in overall MTCT rates, changes in the number of pediatric HIV infections and infant survival rates, expanded ART coverage amongst pregnant and breastfeeding women living with HIV, improved healthcare accessibility, expanded service delivery, and heightened community engagement.

Resource Allocation Disparities

A study assessing the cost of providing MTCT HIV prevention services in Ethiopia found that urban health facilities face higher expenses compared to rural facilities, with costs more than twice as high in some cases. These disparities, driven primarily by the high cost of ART and other healthcare resources, raise concerns about equitable resource allocation and the long-term sustainability of the program. Regional cost differences affect the equity of service and overall financial viability of PMTCT provision.¹⁸

Social and Cultural Barriers

Cultural values, perceptions, and norms have also presented difficulties to the equitable delivery of HIV services. Health-related stigma has been defined as “a social process or related personal experience characterized by exclusion, rejection, blame, or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group identified with a particular health problem.”²⁴ 

HIV stigma manifests in multiple distinct but overlapping forms, including anticipated stigma (fear due to future discrimination), enacted stigma (actual discriminatory acts), and internalized stigma (self-stigma originating from negative perceptions of HIV within the community). These forms of stigma have been proven to limit healthcare access, compromise prevention and treatment efforts, and reduce quality of life.²⁴ 

In rural Ethiopia, stigma associated with HIV often discourages pregnant women from seeking PMTCT services, which impedes efforts to eliminate MTCT.²⁵ Ensuring that all women have accessible services without social exclusion and fear of discrimination would require discussing and overcoming these cultural challenges, confronting and reshaping the stigmatizing attitudes and norms.

Equity Challenges

Immense regional inequities exist in the quality of HIV counseling (HTC) and testing services during antenatal care in Ethiopia. Productive HTC coverage during prenatal care differs greatly across regions, from the Somali region with only 1.6% coverage to 55.5% in Addis Ababa.²³ These gaps highlight ongoing challenges in providing consistent and sufficient PMTCT coverage, particularly in underserved areas like Somalia.

Although Ethiopia’s PMTCT program has successfully reduced HIV transmission rates, unintended consequences put its sustainability and equity in danger. To ensure that all regions, urban and rural, can maintain high-quality service over time, the disproportionate cost burden confronted by urban facilities must be addressed through a reevaluation of more equitable resource allocation. Moreover, mitigating cultural stigma calls for community-driven approaches that promote trust and normalize the routine use of PMTCT services.

Structural inequality, which is defined as systematic and institutional disparities in wealth, access to resources, and power that disadvantage certain groups and are linked to discriminatory institutional practices, is a key feature of this initiative.²⁶ The success of Ethiopia’s PMTCT program was significantly limited by structural inequality. These systemic disparities in wealth, decision-making, and infrastructure have limited access to healthcare for marginalized populations. 

Structural Barriers and Systemic Inequities

Ethiopia’s PMTCT program achieved measurable but highly uneven success between 2001 and 2023, demonstrating the influence of structural inequities on health intervention outcomes. While the program reduced mother-to-child HIV transmission rates in well-resourced urban areas, its national effectiveness was constrained by resource disparities, inadequate rural healthcare infrastructure, and insufficient attention to the social determinants of health. 

There are clear structural inequities in Ethiopia’s HIV testing and counseling services. This is evident in the alarming statistic that nearly 9 out of 10 women do not receive quality HIV testing during prenatal care, with outcomes particularly poor in rural regions.²³ The system designates HIV/AIDS care roles as secondary responsibilities that do not recieve compensation, while budgets inadequately account for staff size and target population needs.²³ This reality is often obscured when the focus shifts to individual behaviors rather than systemic issues. 

Power clearly resides with urban healthcare systems, which “received more investment,” high-level funders who create targets and control the flow of funds, and policymakers—all of whom fail to prioritize enhancing the quality of care.¹⁸ Those with little power include rural healthcare providers facing resource shortages and pregnant women who do not receive quality HTC during prenatal care. Structural inequities limit Ethiopia’s PMTCT program, but it is possible to concretely address structural inequities with proper community involvement, mandated rural resource allocation minimums, healthcare worker compensation for HIV/AIDS roles, and, especially, the integration of affected women’s voices into program design.

Recommendation for Improvement

To enhance the effectiveness of Ethiopia’s PMTCT, interventions must address both structural and process components of quality care. Studies show that the national quality score for HIV testing and counseling services is only 45.2%, with structural quality at 35.4% and process quality at 61.4%.²³

To strengthen the structural components, Ethiopia must institutionalize responsive and equitable budgeting that addresses the persistent rural-urban disparity in resource allocation.²³ Proper recruitment and professional development of dedicated HIV/AIDS personnel are also essential to address the widespread practice of assigning HIV/AIDS roles as secondary responsibilities without compensation, which thwarts the program’s effectiveness.¹⁸ 

To improve processing quality, Ethiopia must strengthen its monitoring and evaluation systems, specifically for PMTCT services, while providing up-to-date training that reflects current WHO guidelines. Creating evidence-sharing platforms between the successful implementations of the program in an urban area and struggling rural facilities has the potential to transfer effective practices. Tailored interventions must target women with low socioeconomic status and rural residency through the implementation of community-level stigma reduction and expanded testing access.²³  

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