Multilevel Drivers of HIV Exposure in Children Under 24 Months in Sub-Saharan Africa: A Multilevel Analysis of Pooled DHS Data
Desalegn Mitiku Kidie, Abraham Dessie Gessesse, Tsegaamlak Kumelachew Derse, Tadios Lidetu, Addisu Simachew Asgai, Jenberu Mekurianew KelkayBackground
HIV exposure among children remains a major public health concern in sub-Saharan Africa despite progress in preventing mother-to-child transmission. This study examined maternal, child, household, and community-level factors associated with HIV exposure among children aged under 24 months.
Methods
We conducted a cross-sectional secondary analysis of pooled Demographic and Health Survey data collected between 2015 and 2024 from 14 sub-Saharan African countries. The analysis included 48,832 mother-child pairs. HIV exposure was defined based on maternal HIV positivity confirmed through biomarker testing. A three-level mixed-effects logistic regression model with random intercepts at the cluster and country levels was fitted to account for the hierarchical structure of the data.
Results
Significant spatial heterogeneity was observed (Median Odds Ratio = 2.39; Intraclass Correlation Coefficient=20.0% at the cluster level). Multivariable analysis revealed that lack of maternal postnatal care (PNC) within two months significantly increased exposure odds (AOR=1.13; 95% CI: 1.02-1.26). At the community level, low HIV-related knowledge was a potent driver of exposure (AOR=1.26; 95% CI: 1.13-1.40). Conversely, low community antenatal care (ANC) coverage was associated with lower reported exposure (AOR=0.71; 95% CI: 0.58-0.86), likely reflecting differences in HIV testing, diagnosis, service access, and ascertainment in underserved regions rather than a protective effect of low ANC coverage.
Conclusions
HIV exposure among children remains an important public health concern in sub-Saharan Africa. Strengthening maternal postnatal care, improving community-level HIV knowledge, and expanding access to HIV testing and follow-up services may help address gaps in the PMTCT continuum. The lower reported exposure in communities with limited ANC coverage may reflect inadequate diagnosis and case ascertainment, highlighting the need for targeted outreach and strengthened surveillance in underserved populations.