Structural determinants of outcomes related to the prevention of vertical HIV transmission: A cross‐country ecological analysis

Objective This study examined the longitudinal associations of epidemiological, health system and structural factors with paediatric HIV infections and antiretroviral therapy (ART) need among pregnant women in 30 high‐burden countries. Methods This longitudinal cross‐country ecological study used secondary data from international databases covering 2000–2024. A total of 30 countries were included based on HIV burden and data availability. Data were sourced from UNAIDS (indicators related to the prevention of vertical HIV transmission), WHO/UNICEF (maternal health services) and the World Bank (socioeconomic variables). Missing data were handled using linear interpolation and last observation carried forward (LOCF) to create a balanced panel. Datasets were harmonized by country and year. Linear mixed‐effects models were used to account for repeated observations within countries, with year included as a fixed effect and country specified as a random‐intercept grouping factor. Results Adult HIV prevalence showed substantial variability across countries and years. In the linear mixed‐effects model, higher adult HIV prevalence was significantly associated with higher levels of log paediatric HIV infections ( B = 0.129, p < 0.001) and log ART need among pregnant women ( B = 0.086, p < 0.001). Higher ANC coverage was significantly associated with lower levels of both log paediatric HIV infections ( B = −0.008, p < 0.001) and log ART need ( B = −0.006, p < 0.001). GDP per capita was not significantly associated with log paediatric HIV infections ( B = −0.00003, p = 0.127), whereas it was positively associated with log ART need ( B = 0.000033, p = 0.004). Paediatric HIV infections decreased significantly over time ( B = −0.059, p < 0.001), while year was not significantly associated with ART need ( B = −0.00088, p = 0.626). Strong country‐level clustering was observed for both outcomes (ICC = 0.921 and 0.975, respectively). Conclusions Higher adult HIV prevalence was associated with higher paediatric HIV infections and ART need, whereas higher ANC coverage was associated with lower levels of both outcomes. GDP showed outcome‐specific associations, and substantial between‐country variability was observed. These findings highlight the importance of epidemic burden and maternal health service coverage in understanding outcomes related to the prevention of vertical HIV transmission.