HIV care continuity for women in postconflict Tigray: assessing mother-to-child transmission rates, infant health and cervical cancer screening

Abstract

INTRODUCTION: The Tigray War (November 2020-November 2022) caused catastrophic health system collapse in northern Ethiopia, with substantial excess mortality and near-total destruction of health infrastructure. The impact on HIV care services remains poorly documented. We comprehensively assessed HIV care continuum recovery across prevention of mother-to-child transmission (PMTCT), HIV-exposed infant care and cervical cancer screening among women living with HIV during the postconflict period. METHODS: We conducted a retrospective multidomain cohort study across seven health facilities in Mekelle City, Tigray, from November 2022 to May 2025. We assessed: (1) mother-to-child transmission (MTCT) rates among 405 HIV-exposed infants using Firth's penalised logistic regression; (2) feeding practices, growth outcomes, cotrimoxazole prophylaxis coverage and retention among 2482 follow-up visits using generalised estimating equations and (3) cervical cancer screening cascade completion among 2515 women living with HIV using mixed-effects logistic regression. RESULTS: Among 405 HIV-exposed infants, 11 were diagnosed HIV-positive, an MTCT rate of 2.72% (95% CI 1.36% to 4.81%). MTCT declined significantly from 5.56% in 2022 to 0% by early 2025 (p=0.0015). All transmissions occurred in primary-level facilities (8.27%), with none in secondary-level facilities (0%). Exclusive breastfeeding occurred in 90.9% of visits (95% CI 89.3 to 92.4%). Growth failure was rare among exclusively breastfed infants (0.48%) but markedly higher among replacement-fed infants (26.2%). Programme retention was 99.8%, mortality 0.2%, and no infants were lost to follow-up. Cervical cancer screening coverage was high (98.6% offered, 98.3% accepted), though only 76.9% completed screening. CONCLUSION: Despite catastrophic health system disruption, facility-based HIV services in post-war Tigray achieved near-elimination of MTCT by 2025, with exceptional retention, prophylaxis coverage and breastfeeding outcomes. Concentration of PMTCT services at secondary-level facilities was strongly associated with reduced transmission. However, these findings represent a selected population successfully accessing services; true population-level outcomes are likely substantially worse. Sustained investment in facility-based services and community outreach is essential for comprehensive HIV care recovery.