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Incidence of Mother-to-Child Transmission of HIV and Associated Factors in Postpartum Women in Cameroon
PhD, Raphael Awah Abong3PhD, Sumelong Sharon Dione Akomoneh4MD, Raoul Tuekam Kayo2PhD, Elvis Achondou Akomoneh2,MSc, MTM, PhD
*Corresponding author: Elvis Achondou Akomoneh, Department of Microbiology and Parasitology, University of Bamenda, Bamenda, Cameroon. eakomoneh@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Tayong PC, Mbunkah HA, Abong RA, Akomoneh SS, Kayo RT, Akomoneh EA. Incidence of mother-to-child transmission of human immunodeficiency virus and associated factors among post-partum women in Cameroon. Int J Matern Child Health AIDS. 2025;14:e015. doi: 10.25259/IJMA_23_2025
Abstract
Background and Objective:
Human immunodeficiency virus (HIV) infection attacks and gradually weakens the immune system by destroying CD4 cells, with the most advanced stage of the infection known as acquired immunodeficiency syndrome (AIDS). Mother-to-child transmission (MTCT) of HIV remains the primary method of infection among children. Understanding the factors contributing to MTCT and current transmission rates is crucial for developing effective prevention strategies during pregnancy, childbirth, and breastfeeding. This study aims to determine MTCT of HIV, assess maternal viral load, and identify transmission-associated factors in the Adamawa Region of Cameroon.
Methods:
Blood samples were collected from 119 mothers living with HIV and their children (mother-infant pair) in 15 different HIV/AIDS treatment units/facilities across the Adamawa Region and analyzed at the Ngaoundere Regional Hospital. Early infant diagnosis was performed using the GenXpert system, and viral load quantification was performed using the Cobas 5800 system.
Results:
The findings showed that the MTCT rate of HIV was 1.7% (2/119), with an incidence rate of 33.6 cases/1000 person-years. Maternal viral load suppression rate was 96.6% (115/119). Among the participants, 47.1% (56/119) had undetectable viral loads (<20 copies/mL) and 49.6% (59/119) had suppressed viral loads of 20–<1000 copies/mL. Only 3.4% (4/119) had unsuppressed viral loads ≥1000 copies/mL. There was no statistically significant association between maternal age, duration of antiretroviral therapy (ART), type of ART, and number of antenatal visits. Significant associations were observed between MTCT and place of birth (p = 0.001) and maternal viral load (p < 0.001).
Conclusions and Global Health Implications:
The transmission rate of HIV infection in infants born to HIV-positive mothers was below the national target of 2%. There was high viral suppression in lactating mothers, which was associated with a high adherence rate to ART. Maternal viral load and delivery location were significant risk factors for transmission.
Keywords
Associated Factors
Cameroon
Human Immunodeficiency Virus
Incidence
Mother-to-Child Transmission
Viral Load
INTRODUCTION
Background of the Study
Infections with human immunodeficiency virus (HIV) target the immune system, particularly white blood cells (CD4 cells), and may advance to acquired immunodeficiency syndrome (AIDS) in severe cases.[1] HIV is mostly transmitted through bodily fluids such as blood, breast milk, semen, and vaginal secretions of an infected person, as well as from an infected mother to the child.[1] Mother-to-child transmission (MTCT) occurs during pregnancy, labor, delivery, or breastfeeding, and it remains the primary method of infection among children.[2] The incidence of HIV in women is up to 8 times higher than in men, which complicates their essential role in procreation by carrying a pregnancy.[3]
HIV continues to be a major public health problem with ongoing transmission in all countries, with some reporting an upward trend in new infections where they were previously declining.[4] Each year, about 1.3 million women and girls with HIV become pregnant.[5] The majority of pediatric HIV infections are due to mother-to-child transmission, affecting an estimated 400,000 infants yearly.[6] Without intervention, MTCT accounts for 15–45% of pediatric infections, but effective interventions can reduce this rate to below 5%.[7] Additionally, about 50% of HIV-infected infants die by the age of 2 without proper treatment.[1] However, with access to prevention, diagnosis, treatment, and care, HIV can be managed as a chronic condition, allowing victims to live long and healthy.[1]
The World Health Organization (WHO) defines the elimination of HIV vertical transmission as the reduction of MTCT rate below 2% and 5% in non-breastfeeding and breastfeeding populations, respectively, and the reduction of new pediatric HIV infection due to MTCT to <50 cases/100,000 live birth.[8] Risk factors for infant infection include advanced maternal disease (stages 3 and 4), lack of antiretroviral intervention for mother and infant, vaginal delivery, mastitis, nipple fissures, breast abscess, prolonged breastfeeding (>12 months), premature delivery, exposure to infectious agents, poverty, and utero alterations.[9]
The WHO, Global Fund, and UNAIDS are working towards ending the HIV epidemic by 2030, in line with Sustainable Development Goal target 3.3. Cameroon has seen a decrease in new HIV infections from 47,958 in 2004 to 9,905 in 2022, but still has the highest infection rate in West Central Africa, particularly in the Adamawa Region.[10] UNAIDS set a target of 95–95–95 in 2020 to diagnose, treat, and suppress viral loads in 95% of people living with HIV by 2025. The introduction of dolutegravir into most antiretroviral therapy (ART) regimens in Cameroon has significantly contributed to achieving the viral suppression target, reducing resistance issues.[11]
Efforts to study the prevalence and risk factors of MTCT have been made, however, primary studies in Cameroon remain very heterogeneous and pose challenges that complicate evidence-based decisions to curb transmission.[12] Hence, this study aimed to determine the transmission rate of HIV from mother to child and evaluate the associated factors after years of enhanced access to HIV testing, treatment, and support for pregnant women in the Adamawa Region of Cameroon.
Objective of the Study
This study aimed to determine the transmission rate of HIV from mother to child, evaluate the viral load in lactating mothers, and identify the associated risk factors in the Adamawa Region of Cameroon.
METHODS
This study was a purposive cross-sectional analysis involving children born to mothers living with HIV. Participants were selected and underwent testing, while associated factors of MTCT were obtained through a well-structured questionnaire (mother–infant pair). The viral load of these mothers was determined, and MTCT records were reviewed to evaluate the transmission rates. Conducted from January to June 2024, targeting 15 treatment units/facilities across the Adamawa Region of Cameroon, which includes Vina, Mbere, Djerem, Mayo Banyo, and Faro et Deo Divisions. Collection sites encompass various hospitals and health centers, such as Ngaoundere Regional Hospital, Meiganga Regional Hospital Annex, Ngaoundere Protestant Hospital, Banyo District Hospital, Tignere District Hospital, Mbe Subdivisional Health Center, Mbonjere Integrated Health Center, Islamic Clinic Ngaoundere, Ngaoundal Subdivisional Health Center, Tibati District Hospital, Beka Guiwang Subdivisional Health Center, Lamidate Health Center, Dang District Hospital, Gawui Health Center, and Catholic Hospital Nord Cifan. The study population included children born to mothers living with HIV, aged up to 18 months (n = 119), and their mothers (n = 119). Children who came for testing without their mothers (with careers) were tested but not included in this study.
Dried blood spot (DBS) from infants collected using big toe alcohol-swabs were transported in a 3-packaged plastic bag with their request forms to the Ngaoundere Regional Hospital for analysis following the GenXpert HIV-1 Qual protocol.[13] From each mother, 4 mL of whole blood was collected, centrifuged, and the plasma was transported in labeled cryotubes on ice-pack cold chain to the Ngaoundere Regional Hospital for testing following the HIV-1 reagent guide.[14] Samples that arrived in the laboratory late were analyzed but not included in this study.
Data on the risk factors were collected using a pretested structured questionnaire containing closed and open-ended questions. The results were checked for completeness and clarity, coded, and entered into Excel spreadsheets (MS Excel 2019) and analyzed using the Statistical Package for Social Sciences (SPSS) software version 20 (IBM SPSS Inc., Chicago, IL, USA). The Pearson Chi-square analysis was done to determine the proportion between categorical variables, groups, and disease. Risk factors influencing disease transmission were analyzed using logistic regression models. However, due to limitations in the positive sample size, only variables with p < 0.25 in the univariate analysis were supported for inclusion in the multivariate analysis. All probabilities were two-tailed, and statistical significance was set at a p < 0.05 at 95% confidence intervals.
Ethical clearance was obtained from the Institutional Review Board of the Faculty of Health Sciences at the University of Bamenda (N°:2024/0632H/UBa/IRB). Written informed consent and assent were secured from all participants. Confidentiality in handling participant information was ensured by the use of specific identifiers (codes), the storage of paper sheets in a locked office, and data entry on a password-protected computer.
RESULTS
Sociodemographic Characteristics
Of the 119 mothers included in the study, 47.1% (56/119) were over 30 years old, with a median age of 30 years and an interquartile range (IQR) of 25–34 years. Among the participants, 64.7% (77/119) lived in urban areas, and 65.5% (78/119) had attained only primary education. In addition, 79.8% (95/119) of the participating mothers were married, with 52.1% (62/119) identifying as housewives. Regarding maternal history, 17.6% (21/119) of the mothers had more than one HIV-exposed child, and 2.5% (3/119) had at least one child infected with HIV through vertical transmission. The children enrolled in this study were mostly between 1 and 3 months of age, with a median age of 6 weeks and an IQR of 5–8 weeks. Of these children, 58.0% (69/119) were female and 42% (50/119) were male [Table 1].
| Variables | Frequency (n=119) | Percentage |
|---|---|---|
| Maternal age (years) | ||
| ≤20 | 9 | 7.6 |
| 21–25 | 23 | 19.3 |
| 26–30 | 31 | 26.1 |
| >30 | 56 | 47.1 |
| Home residence | ||
| Urban | 77 | 64.7 |
| Rural | 42 | 35.3 |
| Educational level | ||
| Primary | 78 | 65.5 |
| Secondary | 33 | 27.7 |
| Tertiary | 8 | 6.7 |
| Maternal occupation | ||
| Salary earner | 5 | 4.2 |
| Business | 22 | 18.5 |
| House wife | 62 | 52.1 |
| Farmer | 22 | 18.5 |
| Student | 8 | 6.7 |
| Marital status | ||
| Married | 95 | 79.8 |
| Single | 24 | 20.2 |
| Number of HIV exposed children. | ||
| One | 98 | 82.4 |
| Greater than 1 | 21 | 17.6 |
| Number of exposed children infected | ||
| None | 116 | 97.5 |
| 1 and above | 3 | 2.5 |
| Type of ART | ||
| TLD | 113 | 95.0 |
| TELE | 6 | 5.0 |
| Child’s age (months) | ||
| 1–3 | 109 | 91.6 |
| 4–6 | 7 | 5.9 |
| 7–12 | 1 | 0.8 |
| >13–18 | 2 | 1.7 |
| Sex of the child | ||
| Male | 50 | 42.0 |
| Female | 69 | 58.0 |
HIV: Human immunodeficiency virus, ART: Antiretroviral therapy,TLD: Tenofovir, Lamivudine, Dolutegravir, TELE: Tenofovir, Lamivudine, Efavirenz
MTCT of HIV
Of the 119 children tested, two were positive for HIV, giving a transmission rate of 1.7% (95% confidence interval: 0.2–5.9%) and an incidence rate of 33.6 cases/1000 person-years. The two positive children were female within the age groups 4–6 months and 7–12 months. The transmission of infection was significantly associated with age (p < 0.001) but not with sex (p = 0.22) [Table 2].
| Variables | EID result | p-value | Transmission rate (95% CI) (%) | |
|---|---|---|---|---|
| ND (%) | D (%) | |||
| Child’s age (months) | ||||
| 1–3 | 109 (100) | 0 | <0.001 | 1.7% (0.2–5.9) |
| 4–6 | 6 (85.7) | 1 (14.3) | ||
| 7–12 | 0 | 1 (100) | ||
| 13–18 | 2 (100) | 0 | ||
| Sex | ||||
| Male | 50 (100) | 0 | 0.22 | |
| Female | 67 (97.1) | 2 (2.9) | ||
HIV: Human immunodeficiency virus, CI: Confidence interval,
EID: Early infant diagnosis, D: Detected HIV-1, ND: HIV-1 not detected, Pvalue <0.05
Viral Load Assessment in Mothers
As shown in Table 3, 56 (47.1%) of mothers had suppressed viral loads (“Not detected”), with a total of 115 (96.6%) of the tested mothers achieving viral load suppression (not detected or suppressed with viral load copies <1000 copies/mL). Four (3.4%) mothers had unsuppressed HIV-1 viral loads (≥1000 copies/mL).
| No. | Variable | Frequency (n) | Percentage | 95% CI |
|---|---|---|---|---|
| 1 | “Not detected” (ND) HIV-1 viral load | 56 | 47.1 | (37.8–56.4) |
| 2 | Suppressed HIV-1 (20 copies/mL to 1000 copies/mL) | 59 | 49.6 | (40.3–58.9) |
| 3 | Unsuppressed HIV-1 (>1000 copies/mL) | 4 | 3.4 | (0.9–8.4) |
HIV: Human immunodeficiency virus, CI: Confidence interval
Factors Associated with MTCT of HIV
The factors associated with MTCT of HIV are summarized in Table 4. Maternal age and ART duration were not significantly associated with MTCT (p = 0.12 and p = 0.21, respectively). Likewise, the mode of delivery and child’s feeding practice also did not show a significant association with the MTCT of HIV. However, there was a significant association between the number of antenatal (ANC) visits and MTCT (p = 0.004), with fewer than four visits having a risk ratio of 0.19 for HIV transmission. The place of birth was also significantly associated with MTCT (p < 0.001), with a lower risk ratio of 0.09 for home births. Notably, lack of antiretroviral prophylaxis was significantly associated with increased transmission risk (p = 0.01, risk ratio of 0.25), and maternal viral load also showed a significant association (p < 0.001). One hundred and seventeen (98.3%) children were exclusively breastfed for 6 months, and 2 (1.7%) children born at home were HIV-positive. Multivariate analysis showed a significant association between the place of birth and maternal viral load (p = 0.00 and p = 0.00, respectively) with the transmission of the infection. Conversely, no significant association was found between the number of ANC visits, infant prophylaxis, and HIV transmission.
| Variables | PCR results | RR | p-value | ||
|---|---|---|---|---|---|
| ND (%) | D (%) | Uni | Multi | ||
| Maternal age (years) | |||||
| ≤20 | 8 (6.7) | 1 (0.8) | 0.05 | 0.12 | NA |
| 21–25 | 23 (19.3) | 0 | |||
| 26–30 | 31 (26.0) | 0 | |||
| >30 | 55 (46.2) | 1 (0.8) | |||
| Duration on ART | |||||
| <1 | 35 (29.4) | 2 (1.7) | 0.05 | 0.21 | NA |
| 2–4 | 28 (23.5) | 0 | |||
| 5–10 | 45 (37.8) | 0 | |||
| >10 | 9 (7.6) | 0 | |||
| ANC visits | |||||
| <4 times | 22 (18.5) | 2 (1.7) | 0.19 | 0.004 | 0.62 |
| ≥4 times | 95 (79.8) | 0 | |||
| Place of birth | |||||
| Home | 10 (8.4) | 2 (1.7) | 0.09 | <0.001 | 0.00 |
| Health facility | 107 (89.9) | 0 | |||
| Mode of delivery | |||||
| (C/S) | 2 (1.7) | 0 | 0.85 | NA | |
| Vaginal delivery | 115 (96.6) | 2 (1.7) | 0.98 | ||
| ARV prophylaxis | |||||
| Yes | 89 (74.8) | 0 | 0.01 | 0.46 | |
| No | 28 (23.5) | 2 (1.7) | 0.25 | ||
| Child’s feeding method. | |||||
| Maternal exclusive breastfeeding | 115 (96.6) | 2 (1.7) | 0.02 | 0.98 | NA |
| Mix feeding | 1 (0.8) | 0 | |||
| Formula exclusive feeding | 1 (0.8) | 0 | |||
| Maternal viral load | |||||
| Not detected | 56 (47.0) | 0 | 0.5 | <0.001 | 0.00 |
| Suppressed | 59 (49.6) | 0 | |||
| Unsuppressed | 2 (1.7) | 2 (1.7) | |||
MTCT: Mother-to-child transmission, HIV: Human immunodeficiency virus, PCR: Polymerase chain reaction, D: Detected HIV-1, ND: HIV-1 not detected, RR: RR: Risk ratio, ART: Antiretroviral therapy,
ANC: Antenatal, ARV: Antiretroviral
DISCUSSION
In an effort to fight against HIV/AIDS, the government of Cameroon, through the Ministry of Public Health and its partners, launched the 2021–2023 national strategic extension plan intended to accelerate the HIV response, reduce incidence, and eliminate MTCT.[15] Following the implementation of Option B+ (systematic initiation of ART in all HIV-1-positive pregnant women regardless of their clinical stage or CD4 cell count),[15], there is a need to assess its impact on vertical transmission rates. This study determined the transmission rate of the disease from mother to child as well as provided a means of assessing the effectiveness of the Cameroon national strategy in reducing MTCT of HIV in the Adamawa Region. We obtained an HIV MTCT rate of 1.7% in the Adamawa Region, a significant decrease from the previous rates of 17.5% in the region and 14.2% nationally prior to the implementation of the national strategic plan in 2021.[12,15] This indicates a positive trend following the implementation of the national strategic plan and highlights the feasibility of achieving the national targets to reduce the incidence of MTCT of HIV to <2% at 6 weeks and <5% at 18 months by 2023. This also shows that Cameroon could be on track to attain the goal of eliminating MTCT of HIV by 2030.[15] On the other hand, the MTCT rate was higher than the 1.4% reported in Dar es Salaam, Tanzania, among women on lifelong antiretroviral.[16]
Maternal viral load and timing of ART initiation are important predictors of MTCT of HIV.[17] ART initiation prior to conception and maintaining a viral load of 50 copies/mL or less throughout pregnancy and delivery have been shown to reduce MTCT rates of HIV to levels below the WHO target for elimination of MTCT.[17,18] Our study had 59 of the 119 (47%) mothers with undetectable viral loads (<20 copies/mL), likely contributing to the low MTCT rate of HIV obtained, underpinning the importance of implementing Option B+ in pregnant women. The overall proportion of viral suppression among lactating mothers on ART (not detected and <1000 copies/mL) was 96.6%. This percentage exceeds the 95% target set by UNAIDS for 2025.[6] On the other hand, four (3.7%) of the lactating mothers had unsuppressed viral loads of more than 1000 copies/mL. The effectiveness of viral undetectability in ensuring viral untransmissibility in resource-limited settings like Cameroon remains a challenge, and there is a need to reinforce an integrated approach where access and adherence to ART, and awareness of HIV prevention methods as key in reducing transmission.[11,19]
Several factors are associated with MTCT of HIV among HIV-exposed infants, including the absence of ARV prophylaxis for the baby, mothers with no preventive MTCT interventions, mothers failing to disclose their HIV status to their partners or families, and home delivery.[20] This study identified a significant association between the number of ANC visits and MTCT of HIV, as increased ANC visits enhance opportunities for HIV testing, counseling, and the provision of antiretroviral treatment to prevent transmission.[21] The lack of antiretroviral prophylaxis was also significantly associated with increased HIV transmission risk, as effective ART reduces viral load, and when suppressed to undetectable levels, transmission is preventable. Maternal viral load strongly correlated with MTCT, with cases arising from mothers with unsuppressed viral loads. This finding is similar to what was reported in Tanzania, emphasizing that HIV-positive mothers with an unsuppressed viral load are more likely to transmit the virus to their children compared to mothers with a lower (suppressed) viral load.[22] Another study has linked high levels of maternal viral HIV RNA to a higher risk of MTCT of HIV, with transmission associated with detectable (≥50 copies/mL) and unsuppressed viral load (≥1000 copies/mL).[23] Place of birth was also significantly associated with MTCT of HIV, as both positive babies tested in this study were delivered at home. This could be because local/traditional birth attendants may assist these mothers under poor septic conditions, and the HIV-exposed newborns would be less likely to receive ARV prophylaxis as soon as they are born compared to those in the hospital, where there is proper follow-up.[24]
Limitations of the study
Some limitations of this study included the lack of data on measuring ART adherence and the objective assessment of exclusive versus mixed breastfeeding. Also, this study measured viral load at a single point, which may not accurately represent the women’s viral load burden. The self-reported timing of ART initiation data may be susceptible to recall bias. We did not collect information about the ART regimen that the mothers had been put on, nor did we administer any tool or test to assess ART adherence. Hence, we cannot infer the effect of these factors on our results. Another limitation of the study was that we did not consider potential confounders, such as CD4 count, opportunistic diseases, in the analysis, as we did not collect this information.
CONCLUSION AND GLOBAL HEALTH IMPLICATIONS
In the Adamawa Region of Cameroon, the HIV transmission rate among infants born to HIV-positive mothers taking ART is 1.7%, with the incidence rate of 33.6 cases per 1000 person/years. The viral load suppression rate among these mothers is high at 96.6%, indicating that ART programs can be highly effective when well-implemented, even in resource-limited settings. This reinforces global public health strategies that promote universal access to ART for pregnant women living with HIV. Unsuppressed maternal viral load (>1000 copies/mL) and MTCT underscore the critical need for routine viral load monitoring during pregnancy. This emphasizes the importance of strengthening laboratory infrastructure and ensuring timely interventions for women with high viral loads.
Additionally, home delivery is significantly associated with the MTCT of HIV. This suggests that institutional delivery in a healthcare setting is crucial in preventing MTCT of HIV. This has global implications for improving healthcare access, education, and delivery infrastructure, particularly in rural areas.
Key Messages
1. We observed a low mother-to-child transmission rate of HIV following the 2021-2023 national strategic extension and the implementation of Option B+ indicating that ART programs can be highly effective when well implemented, even in resource-limited settings. 2. Home delivery was significantly associated with the MTCT of HIV.
Acknowledgments: We would like to extend special thanks to the entire HIV/AIDS staff at Ngaoundere Regional Hospital and HIV/AIDS focal point persons in all the different HIV units in the Region for their tremendous support. We extend our sincere gratitude to the mothers living with HIV and their infants in the Adamawa Region who participated in this study.
COMPLIANCE WITH ETHICAL STANDARDS
Conflicts of Interest: The authors declare no competing interests; Financial Disclosure: Nothing to declare. Funding/Support: There was no funding for this study. Ethics Approval: The research/study was approved by the Institutional Review Board at the Faculty of Health Science, University of Bamenda, number 2024/0632H/UBa/IRB, dated January 02, 2024. Declaration of Patient Consent: The authors certify that they have obtained all appropriate patient consent. Use of Artificial Intelligence (AI)-Assisted Technology for Manuscript Preparation: The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI. Disclaimer: None.
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