ABSTRACT Despite the dramatic decline in the incidence of common opportunistic infections (OIs) after antiretroviral therapy initiation, they remain a significant cause of morbidity and

mortality among children with HIV. For better interventions, information regarding the incidence and predictors of common OIs is essential for Children living with HIV. Still, there is a

lack of studies in low and middle-income countries, including Ethiopia. Therefore, this study aims to assess the incidence and predictors of common OIs among Children living with HIV on

anti-retroviral therapy (ART) at public health institutions in Bahir Dar City, Northwest Ethiopia. The reasons for excluding children not on ART is we want to study the effectiveness of

2010 to 2020. Data was entered using Epi-data version 4.6 and analyzed using STATA 14.0. A bivariable Cox-proportional hazards regression model was employed to appreciate the relationship

between each explanatory variable with the outcome variable. In the bivariable analysis, variables with a _p_-value of less than 0.25 were candidates for the multivariable proportional

hazard model. The Cox proportional hazards model was used to determine predictors of common opportunistic infections at a 5% significance level. The overall incidence rate of common

opportunistic infections was 7.06 with a 95% confidence interval ((CI) 5.78, 9.75) per 100 person-years of observation. Statically significant predictors were World Health Organization (WHO)

clinical stage III and IV (adjusted hazard ratio (AHR) = 1.90; (95% CI 1.34, 2.75), having fair/poor adherence to anti-retroviral therapy (ART) (AHR) = 1.80; (95% CI 1.25, 2.94) and

hemoglobin level < 10 g/dl (AHR) = 2.00; (95% CI 1.36, 2.89). The overall incidence rate of common OIs among children living with HIV on ART was high. Independent predictors of common OIs

among children on ART were advanced-stage of HIV disease, poor ART adherence, and lower hemoglobin level. Therefore, we recommend strongly working on the prevention of advanced stages of

HIV disease and improving poor ART adherence to prevent the incidence of OIs among children living with HIV on ART. SIMILAR CONTENT BEING VIEWED BY OTHERS INCIDENCE AND PREDICTORS OF LOST TO

FOLLOW UP AMONG CHILDREN RECEIVING ANTIRETROVIRAL THERAPY A COMPUTING RISK REGRESSION MODEL Article Open access 20 May 2025 EFFECT OF HIGHLY ACTIVE ANTIRETROVIRAL TREATMENT ON TB INCIDENCE

AMONG HIV INFECTED CHILDREN AND THEIR CLINICAL PROFILE, RETROSPECTIVE COHORT STUDY, SOUTH WEST ETHIOPIA Article Open access 08 December 2020 STATISTICAL ANALYSIS ON THE INCIDENCE AND

PREDICTORS OF DEATH AMONG SECOND-LINE ART PATIENTS IN PUBLIC HOSPITALS OF NORTH WOLLO AND WAGHEMIRA ZONES, ETHIOPIA, 2021 Article Open access 13 May 2024 INTRODUCTION The HIV epidemic is

still a major public health concern1. In 2020, around 37.7 million people were infected with HIV globally. Among these, 36.0 million were adults, and 1.7 million were children less than 15 

years of age2. Sub-Saharan Africa3 is the most affected part of Africa4, with Ethiopia being one of the top 25 countries with the highest rate of new HIV infections5. Opportunistic

infections (OIs) occur among people with weaker immune systems and are more frequent and severe, especially in Children living with HIV6. Immunosuppression is a characteristic of HIV

infection, and it predisposes to OIs, increasing morbidity and death in Children living with HIV around the world7,8,9. As a result, it is vital to prevent opportunistic infections in

HIV-positive children10,11. All Children living with HIV patients are at risk of developing a wide range of OIs12. However, the proportion and incidence of HIV-related OIs differ

significantly13,14. The majority of studies conducted on the proportion of OIs among Children living with HIV were reported from North America and Europe. The exact magnitude and incidence

of OIs in Children living with HIV in SSA, especially in Ethiopia, remains poorly documented15. Even though effective HIV prevention, diagnosis, and treatment are becoming more widely

available worldwide16, OIs are the most common cause of morbidity and death among children living with HIV, accounting for 94.1% of deaths reported related to HIV17,18. Even though the

global incidence of OIs dropped dramatically after the introduction of ART14,19, they are a major cause of poor clinical outcomes, hospital admission, and poor ART drug adherence among

Children living with HIV in Ethiopia7,20,21. Unless OIs are managed appropriately and on time, they significantly impact on Children living with HIV treatment outcomes. This leads to

accelerating disease progression, poor clinical outcomes, increased health care costs, increased possibility of developing treatment failure, and unsatisfactory response to ART drugs3. In

developing countries, the most common types of OIs are tuberculosis, pneumonia, oesophagal candidiasis, chronic diarrhea, oral candidiasis, _Pneumocystis_ jiroveci pneumonia, wasting

syndrome, herpes zoster, and different kinds of skin infections17,22,23. There are different types of recommendations developed by the World Health Organization (WHO) to reduce the incidence

of OIs among Children living with HIV. Those medical interventions include reducing exposure, giving primary or secondary chemoprophylaxis, and immediate initiation of ART drugs after HIV

diagnosis is confirmed24. The use of antiretroviral therapy (ART) has effectively reduced OIs significantly among Children living with HIV and adolescents25. Additionally, in Children living

with HIV co-trimoxazole is highly effective for the treatment and prevention of _Pneumocystis_ jiroveci pneumonia, bacterial infections, malaria, and isosporiasis11. Similarly, the Federal

Ministry of Health, Ethiopia (FMOH) has been implementing different medical interventions to increase the survival of children living with HIV, like the ART coverage of Children living with

HIV, which reached 34% in 201724. Even though the incidence of OIs has decreased dramatically after the introduction of ART, they continue to be a significant cause of morbidity and

mortality in these vulnerable age groups9. Most HIV-related OIs and other comorbidities can be prevented and treated with cost-effective medical interventions. Even if, for better

interventions, data on the incidence and predictors of common OIs is essential for all age groups, especially in Children living with HIV, still there is limited data in developing

countries, including Ethiopia. So, the current study aims to assess the incidence and predictors of common OIs among children living with HIV on ART at the public health institutions of

Bahir Dar City, Northwest Ethiopia. The results found from this study provide valuable contributions for health care professionals and clinicians by advancing the existing knowledge,

enabling prioritization of identified predictors, to implementing measures for prevention and management of common OIs. The study also provides input to program planners and decision-makers

at various levels to plan appropriate interventional strategies to decrease the incidence of common OIs among children living with HIV. Additionally, the findings serve as baseline data for

further research and academic education. METHODS AND MATERIALS STUDY DESIGN, SETTING, AND PERIOD A health institution-based retrospective cohort study was conducted at a public health

institution in Bahir Dar City, Northwest Ethiopia. Bahir Dar City is located 565 km from Addis Ababa, the capital city of Ethiopia. Based on the 2020 Bahir Dar City Administration Health

Department report, the total population is 389,177. Of these, 147,983 were children under 15 years of age. The city has three governmental hospitals (one specialized teaching hospital, one

comprehensive specialized referral hospital, and one primary hospital) and ten governmental health centres. Of the governmental health institutions, two hospitals and eight health centres

provide ART chronic care services for children living with HIV. From those health institutions, there are a total of 1,117 children living with HIV who have started ART since ART service

started, additionally; there are a total of 763 living HIV- infected children who are currently on ART. Data were extracted from the charts belonging to the children, who started ART

follow-ups between September 1, 2010, and December 31, 2020. SOURCE POPULATION All children living with HIV under 15 years of age who started ART at the public health institutions of Bahir

Dar City ART clinic. STUDY POPULATION All children living with HIV under 15 years of age who started ART at the public health institution of the Bahir Dar City ART clinic from September 1,

2010, to December 30, 2020. ELIGIBILITY CRITERIA INCLUSION CRITERIA All children living with HIV less than 15 years of age who have a follow-up at the ART clinic from September 1, 2010, to

December 30, 2020. EXCLUSION CRITERIA Children who had OIs at the time of ART initiation and those who had OIs before the study period were excluded from the study. In addition to this,

children on ART who have incomplete chart records, especially important variables like age, sex, serum HGB level, weight, height, ART regimen, date of ART initiation, and date of an event or

censored report, were excluded from the study. SAMPLE SIZE DETERMINATION AND SAMPLING PROCEDURE The sample size was calculated by using the Log-rank test through open STATA version 14.0

statistical software by considering the following assumptions. 95% of CI, AHR = 2.6, exposed to unexposed ratio 1:1, margin of error 5%, power 80%, and 10% for incomplete chart records. We

have calculated by taking significantly associated predictors for the incidence of OIs having fair or poor ART adherence as an exposed group (0.47) and having good ART adherence as an

unexposed group (0.29), from a previous study17. The final calculated sample size was 422. First, all public health facilities providing ART services in Bahir Dar City were identified. Then,

the lists of children who had started ART during the study period were obtained from their registration books and electronic databases in each health institution. Next, the sampling frame

was constructed by merging the medical records of the children on ART from each health institution. Finally, from the constructed sampling frame, children living with HIV were selected

randomly by using a computer-generated simple random sampling technique. A total sample size of 422 children living with HIV was selected from the health institution (Fig. 1). STUDY

VARIABLES The dependent variable was the incidence of any type of OIs during the follow-up time. The independent variables include socio-demographic variables of the child (age, sex,

residence, family size, and current status of parents). The socio-demographic variables of the caregiver were age, HIV status, occupation, educational status, relationship with the child,

and marital status. Clinical, laboratory and treatment-related characteristics (WHO clinical stage, CD4 count or percentage, serum hemoglobin level, nutritional status, initial ART regimen,

time of ART initiation, ART regimen change, duration on ART, level of ART adherence, co-trimoxazole preventive therapy (CPT), isoniazid preventive therapy (IPT), ART drug side effects, and

viral load copies). Those variables mentioned above were taken from clients’ chart records in HIV chronic care (intake and follow-up form) prepared by WHO, which are very important variables

for children living with HIV on ART. OPERATIONAL DEFINITIONS _Event_ when children living with HIV developed any form of OIs after ART initiation during the follow-up period. _Censored_

when children living with HIV withdraw, are lost, transfer out, die, or do not develop any types of OIs until the study period ends. _ART initiation_ it can be explained as early initiation

or late initiation. Early initiation: defined as ART initiation within seven days of HIV diagnosis provided no contraindications. Late initiation: defined as ART initiation after seven days

of HIV diagnosis. _Children_ it is defined as the age of the study participants is less than 15 years old. _Nutritional status_ classified as well-nourished, mild malnourished, moderately

malnourished, and severely malnourished. _Well-nourished_ according to WHO growth curve weight/age < 1 & ≥ − 1 z score, height/age < 1 & ≥ − 1 z score, weight/height < 1

& ≥—1 z score. _Mild undernutrition_ according to WHO growth curve weight/age < − 1, ≥  − 2 z score, height/age < − 1, ≥  − 2 z score, weight/height < − 1, ≥  − 2 z score.

_Moderate undernutrition_ according to WHO growth curve weight/age < − 2, ≥  − 3 z score, height/age < − 2, ≥  − 3 z score, weight /height < − 2, ≥  − 3 z score. _Severe

undernutrition_ according to the WHO growth curve weight/age < − 3 z score, height/age < − 3 z score, weight/height < − 3 z score. _ART Adherence_ is defined as “good” if the child

took ≥ 95% (missing one from 30 doses or three out of 60 doses), “fair” if the child took 85–94% (missing 2–4 doses out of 30 doses or 4–9 from 60 doses or “poor” if the child took < 85%

(missing ≥ 5 doses from 30 doses or > 10 from 60 doses during follow up24. _Exposed_ those patients who had fair or poor ART adherence during the follow-up period. _Unexposed_ those

patients who had good ART adherence during the follow-up period. _Relation of the caregiver to the child_ it is defined as if the child is living and getting care from parents, other

relatives or guardians. _Opportunistic infections_ occur more frequently and seriously among populations with weaker immune systems, including children living with HIV6. According to the

Ethiopian ART guidelines, the common OIs include herpes zoster, bacterial pneumonia, pulmonary TB, oral candidiasis, esophageal candidiasis, chronic diarrhea, _Pneumocystis_ jiroveci

pneumonia, Cryptococcal meningitis, non-Hodgkin’s lymphoma, Kaposi’s sarcoma, cervical cancer, wasting syndrome, and others24. DATA COLLECTION TOOL AND PROCEDURE Data was extracted from

children living with HIV charts using a standardized and pre-tested data extraction tool developed from WHO ART follow-up forms and intake forms and included by reviewing related literature.

children living with HIV socio-demographic, treatment-related clinical and laboratory-related variables were collected. Three Bachelor of Science (BSc) nurses who have ART training

certificates were selected for data collection. One BSc public health professional with a comprehensive ART training certificate was selected for supervision of the data collection process.

Medical registration numbers were used to track the charts from the computer database as well as in the card room. DATA QUALITY ASSURANCE One week before the actual data collection period, a

pre-test was done at Addisalem Primary Hospital among 22 medical records of children living with HIV on ART using a prepared data extraction tool to check the consistency of the tool and

availability of study variables. Two days of training were given for data collectors to review the documents and extract data from medical records, and for one supervisor, how to supervise

the whole data collection process, and the filled formats were checked for completeness by the supervisor and principal investigator each day. Data cleaning was done during data collection

and analysis time. Once data was extracted from children’s charts, it was coded to eliminate duplication of charts. DATA PROCESSING AND ANALYSIS The data was coded and entered into EPI data

version 4.6 then; it is exported to STATA 14.0 for further cleaning and analysis. Frequencies and proportions were calculated for descriptive statistics. The correlation coefficient and

variance inflation were used to check for multicollinearity between different variables. The log–log plot of the survival estimates and a scaled Schoenfeld residual test were used to assess

the Cox proportional hazard model assumption (a _p_-value greater than 0.05 met the assumption). The cox–Snell residual test was used to assess the overall model fitness. The incidence rate

of OIs was calculated using person-years of observation as a denominator for the entire study period. I.e incidence rate = Number of new cases during a follow-up period / (total person-time

observation). The Kaplan–Meier survival curve was used to estimate the OIs-free probability time and survival function estimation among different groups of categorical explanatory variables

to compare with the support of the log-rank test. A bivariate Cox-proportional hazards regression model was performed for each independent variable to test the relationship with the

dependent variable. Variables with a _p_-value of less than 0.25 in the bivariable model were eligible for the multivariable proportional hazard model. In addition to a _p_-value, we were

considering epidemiologically and clinically relevant variables, even if their _p_-value is greater than 0.25 in the bivariable analysis. A 95% CI of the hazard ratio was computed, and

variables with a _p_-value less than 0.05 in the multivariable model were considered significantly associated with the dependent variable. RESULTS BASELINE SOCIO-DEMOGRAPHIC CHARACTERISTICS

OF CHILDREN ON ART A total of 422 charts were reviewed. Of those, 403 medical records of children living with HIV on ART were included in the analysis, which provided a completeness rate of

95.5%. The median age of children living with HIV during ART initiation was eight years, with interquartile range (IQR)5,10. More than half (53.35%) of the participants were males. The

majority (82.13%) of children living with HIV were from urban areas, and two-thirds (66.50%) of the children had a family size of less than three (Table 1). BASELINE SOCIO-DEMOGRAPHIC

CHARACTERISTICS OF CAREGIVERS AND PARENTS More than half (62.03%) of the children living with HIV caregivers, both mother and father, were alive, and almost more than two-thirds (90.07%) of

the children living with HIV lived with their parents. More than half (62.03%) of the parents were married. More than one-third (44.67%) of children living with HIV parents (both father and

mother) were living with HIV (Table 2). BASELINE CLINICAL, LABORATORY AND ART INFORMATION OF CHILDREN ON ART More than two-thirds (84.37%) of Children living with HIV took co-trimoxazole

prophylaxis during ART initiation. Regarding to initial ART regimen, 37.46% of children were initiated with a combination of AZT-3TC-NVP. Of the total children living with HIV, about 45.66%

of the children were stunted, and 42.18% of participants were underweight (Table 3). FOLLOW-UP LABORATORY AND ART INFORMATION The majority (88.09%) of children had good ART adherence during

their follow-up. Two-thirds (66.75%) of children living with HIV have changed their original ART regimen. The major (52.79%) reason for changing the regimen was the availability of new drugs

(Table 4). INCIDENCE OF COMMON OIS DURING THE FOLLOW-UP PERIOD A total of 403 children living with HIV were followed for the overall follow-up period of 1587 person-years of observation,

with a minimum of one month and a maximum of 123 months. From the censored group, 55.33% never developed OIs, 3.47% were lost to follow-up, 11.66% were transferred out to other health

institutions, and 1.74% died. During the follow-up period, more than one-fourth (27.80%) (95% CI 23.12, 30.43) of children living with HIV developed OIs. The overall incidence rate during

the follow-up period was 7.06 (95% CI = 5.78, 9.75) per 100 person-years of observation. Of all types of OIs occurring during the follow-up period, pneumonia (32.14%) was the most common,

followed by tuberculosis (19.64%), herpes zoster (14.28%), oral candidiasis (11.60%), wasting syndrome (8.92%), esophageal candidiasis (6.25%), chronic diarrhea (4.46%) and others (2.67%)

(Fig. 2). Common OIs-free survival probability of children living with HIV by the end of the follow-up period was 57% (95% CI = 53.65, 61. 86) (Fig. 3). LOG-RANK TEST RESULT COMPARISON ON

DIFFERENT PREDICTOR VARIABLES A log-rank test was performed to test the equality of survival curves for different predictor variables. The test statistics showed a significant difference in

survival function in different categorical predictor variables. Children living with HIV presented with WHO clinical stages III & IV at baseline had lower OIs survival times as compared

to children living with HIV presented with WHO clinical stages I & II. The median survival time of OIs-free children with stages III and IV was 118 months. The overall survival of

children with WHO clinical stages III and IV and WHO clinical stages I and II was 42% and 70%, respectively (Fig. 4). Additionally, children living with HIV with fair or poor ART adherence

levels during follow-up had lower OI survival times as compared to children living with HIV with good ART adherence levels. The overall survival of children with fair or poor ART adherence

levels and good ART adherence levels was found to be 37% and 68%, respectively. This difference was statistically significant, with a _p_-value of 0.0047 (Fig. 5). Similarly, children who

had a serum hemoglobin level of less than 10 g/dl had a lower OIs survival time than children who had a serum hemoglobin level ≥ 10 g/dl during ART initiation. PREDICTORS OF COMMON OIS AMONG

CHILDREN LIVING WITH HIV ON ART The temporal relationship between the baseline and follow-up variables and the hazard of common OIs in children living with HIV on ART was analyzed using the

Cox proportional hazard regression model. In the multivariable analysis, WHO clinical stage, ART adherence level, and serum hemoglobin level were identified as independent predictors of

common OIs. This study finding showed that the hazard ratio of developing OIs in children with WHO clinical stages III and IV had increased 1.92 (1.28, 2.67) times compared to children with

WHO clinical stages I and II. Additionally, children who presented with fair/poor ART adherence had increased hazard ratio of OIs by 1.85 (1.36, 2.83) times compared to children who had good

ART adherence levels during the follow-up time. Furthermore, children with a serum hemoglobin level of less than 10 g/dl had an increased hazard ratio of OIs by 2.06 (1.31, 2.72) times

compared to those children with a serum hemoglobin level greater than 10 g/dl (Table 5). DISCUSSION This study aimed to analyze the incidence and predictors of common OIs among children

living with HIV on ART at the public health institutions in Bahir Dar City. During the study period, the overall incidence density rate was 7.06 per 100 person-years of observation, and the

cumulative incidence proportion was 27.80%. Among all types of OIs occurring during the follow-up period, pneumonia was the most common, followed by tuberculosis and herpes zoster. In

bivariable analysis, the Cox proportional hazard regression model showed the age of the child, the relationship of the caregiver to the child, co-trimoxazole prophylaxis, isoniazid

prophylaxis, WHO clinical stage, height for age, weight for age, BMI for age, serum hemoglobin level, and ART adherence level were identified as predictors of common OIs. But in the

multivariable analysis, only WHO clinical stage III and IV, fair or poor ART adherence level, and lower hemoglobin level were independent predictors of common OIs among children on ART in

the current study. This study’s overall incidence density rate was consistent with the previous study conducted in Ethiopia, which reported 9.7 per 100 child-years of observation17. Because

the incidence rate of our study is found between the confidence interval of the previous study (95% CI 7.02–11.48). However, the incidence rate found in the current study was higher than

that of another study done in Ethiopia [5.3 per 100 person-years]26. This discrepancy might be due to differences in outcome variable criteria because the current study reports all types of

common OIs. In contrast, the above-mentioned study reports only the incidence rate of advanced OIs. Similarly, the incidence rate of common OIs found in this study was lower than that

reported in the study conducted in Asia, which reported 10.5 per 100 person-years9. The possible explanation for this difference might be due to differences in follow-up periods and study

settings because the follow-up period of the previous study was very long (16 years follow-up) when compared to the current study (10 years follow-up). On the other hand, the incidence rate

of common OIs found in our study was higher than the studies conducted in Brazil [2.63 per 100 person-years]18, Latin America [1.1 per 100 person-years]27 and the United States of America

[4.99 per 100 person-years]28. The possible justification for this discrepancy might be that developed countries have better healthcare services for early prevention, diagnosis, and

treatment of common OIs among children living with HIV compared to developing countries like Ethiopia. Moreover, there is a lack of awareness among people living with HIV/AIDS to take ART

drugs and OI prophylaxis medications properly29, which contributes to the increasing Incidence of common OIs in developed countries. The current study revealed that among all types of common

OIs, pneumonia [32.14%] was the most common OI occurring during the follow-up period. This finding is in line with the studies conducted in the United States of America28, Latin America

[34.1%]22, China [42.1%]30, and a previous study of Northwest Ethiopia [35.63%]26. But, the previous studies conducted in Ethiopia [29.8%]17 and India [28%]31 reported that the most common

type of OI was TB even if, Ethiopia launched a TB treatment and prevention strategy. Additionally, the current study reported that among the common OIs, herpes zoster accounts for around

14.28% of children living with HIV in the study area. This is an important finding not found in the previous studies conducted in different places. But there are some difficulties in

confirming the diagnosis of some OIs since the diagnostic methods vary widely between varying levels of health institutions. The current study showed that the hazard of developing common OIs

in children living with HIV presented with WHO clinical stages III and IV during ART initiation increased as compared to children presented with WHO clinical stages I and II during ART

initiation. This finding is supported by the studies conducted in Ethiopia17, Asia9, and India8. It can be explained that being in the advanced stage of the disease causes compromised

immunity, which leads to increased viral multiplication and higher loads of opportunistic infections. As a result, as the WHO clinical stage becomes more advanced, the occurrence of OIs also

increases. The most severe and life-threatening OIs have become more common among children living with HIV with WHO clinical stages III and IV. Similarly, in this study, children with fair

or poor ART adherence levels during the follow-up period increased the hazard ratio of developing OIs as compared to those with good ART adherence levels. This finding is consistent with the

studies conducted in Ethiopia17,26 and Cameroon32. The possible explanation for this might be that those children who had fair or poor ART adherence levels are at a greater risk of high

viral load duplication, suppression of immunity, fast progression of the disease, and drug resistance, which leads to opportunistic infections. Furthermore, this study showed that the risk

of developing common OIs in children who had hemoglobin levels of less than 10 g/dl during ART initiation was higher than that of children who presented with hemoglobin levels of ≥ 10 g/dl

during the initiation of ART. This finding is supported by the studies done in Ethiopia26, Nigeria33, and Uganda34. This is because anemia will influence children living with HIV by

accelerating the rate of disease progression, resulting in multisystem disabling symptoms, fatigue, and exhaustion, which leads to poor quality of life and more occurrences of OIs35.

Moreover, children living with HIV with low hemoglobin levels and low CD4 count had a greater risk of morbidity and mortality36,37. Lastly, when we see OIs-free survival time in the current

study, most common OIs occur within 50 months of starting ART drugs. This is another new finding that has not been reported in the previous studies conducted in different areas. So, this

indicates that there is a need for great attention to children living with HIV, especially within the first four years of ART initiation. LIMITATIONS OF THE STUDY Since the data were

collected from a secondary source of medical records, other important predictors of common OIs that were assessed by primary data were not identified. There were difficulties in confirming

the diagnosis of a few OIs since the diagnosis may vary widely, like cryptococcal meningitis. In addition, we faced difficulty assessing all children living with HIV in the cohort because of

the scarcity of resources. There might be selection bias because there were incomplete charts that were excluded from the analysis; this may underestimate the incidence of OIs among

children living with HIV on ART. CONCLUSION The overall incidence rate of common OIs among children living with HIV on ART was high compared to other developed countries reports. Independent

predictors of common OIs among children on ART were WHO clinical stage III and IV, fair or poor ART adherence level, and lower hemoglobin level. Therefore, we recommend strongly working on

the prevention of advanced stages of the disease, improving fair/poor ART adherence levels, and monitoring and treating low hemoglobin levels to prevent the incidence of common OIs among

children living with HIV on ART. For future researchers, we recommend assessing the incidence of OIs and their predictors using a prospective follow-up study design to address predictors

which are not addressed by the current study. Policymakers should strengthen good ART adherence to reduce OIs. DATA AVAILABILITY The datasets generated during the current study are not

publicly available due to confidentiality issues since the study was conducted among children living with HIV. But data will be available upon reasonable request from the corresponding

author. ABBREVIATIONS * AHR: Adjusted hazard ratio * AIDS: Acquired immunodeficiency syndrome * ART: Antiretroviral therapy * AZT: Zidovudine * BMI: Body mass index * CD4: Cluster of

differentiation 4 * CHR: Crude hazard ratio * CI: Confidence interval * CPT: Cotrimoxazole prophylactic therapy * EDHS: Ethiopian demographic health survey * HAART: Highly active

antiretroviral therapy * HIV: Human immunodeficiency virus * HGB: Hemoglobin * IRB: Institutional review board * OIs: Opportunistic infections * TB: Tuberculosis * WHO: World Health

Organization REFERENCES * Gayle, H. D. & Hill, G. L. Global impact of human immunodeficiency virus and AIDS. _Clin. Microbiol. Rev._ 14(2), 327–335 (2001). Article  CAS  PubMed  PubMed

Central  Google Scholar  * Global HIVAIDS Statistics Report. FACT SHEET [Internet]. https://www.unaids.org/en/resources/fact-sheet. (2021) * Sisay, M. M. _et al._ Incidence and risk factors

of first-line antiretroviral treatment failure among human immunodeficiency virus-infected children in Amhara regional state, Ethiopia: a retrospective follow-up study. _BMJ Open._ 8(4),

e019181 (2018). Article  PubMed  PubMed Central  Google Scholar  * Global HIVAIDS statistics Report, fact sheet 2014 [Internet]. 2014. Available from:

https://files.unaids.org/en/media/unaids/contentassets/documents/factsheet/2014/20140716_FactSheet_en.pdf. * HIV Prevention in Ethiopia National Road Map 2018–2020 FINAL [Internet].

https://ethiopia.unfpa.org/sites/default/files/pub-pdf/HIV%20Prevention%20in%20Ethiopia%20National%20Road%20Map%202018%20-%202020%20FINAL_FINAL.pdf. (2018). * AIDS and Opportunistic 2018

[Internet]. https://www.cdc.gov/hiv/basics/livingwithhiv/opportunisticinfections.html. (2018). * Marais, B. J., Rabie, H., Schaaf, S. H. & Cotton, M. F. updAIDS review: common

opportunistic infections in HIV infected infants and children part 1-respiratory infections. _South Afr. Fam. Pract._ 48(10), 52–56 (2006). Article  Google Scholar  * Dhaka, G., Sherwal, B.,

Saxena, S., Rai, Y. & Chandra, J. Current trends in opportunistic infections in children living with HIV/AIDS in a tertiary care hospital in northern India. _Indian J. Sex. Transm. Dis.

AIDS._ 38(2), 142 (2017). Article  PubMed  PubMed Central  Google Scholar  * Prasitsuebsai, W. _et al._ Impact of antiretroviral therapy on opportunistic infections of Children living with

HIV in the TREAT Asia pediatric HIV observational database. _Pediatr. Infect. Dis. J._ 33(7), 747 (2014). Article  PubMed  PubMed Central  Google Scholar  * Moore, R. D. & Chaisson, R.

E. Natural history of HIV infection in the era of combination antiretroviral therapy. _AIDS_ 13(14), 1933–1942 (1999). Article  CAS  PubMed  Google Scholar  * Chintu, C. _et al._

Co-trimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP): A double-blind randomised placebo-controlled trial. _Lancet_ 364(9448), 1865–1871

(2004). Article  CAS  PubMed  Google Scholar  * World Health Organization. _Global health sector strategy on HIV 2016–2021_ (2016). * Kharsany, A. B. & Karim, Q. A. HIV infection and

AIDS in sub-Saharan Africa: Current status, challenges and opportunities. _Open AIDS J._ 10, 34 (2016). Article  CAS  PubMed  PubMed Central  Google Scholar  * Low, A. _et al._ Incidence of

opportunistic infections and the impact of antiretroviral therapy among HIV-infected adults in low-and middle-income countries: a systematic review and meta-analysis. _Clin. Infect. Dis._

62(12), 1595–1603 (2016). Article  PubMed  PubMed Central  Google Scholar  * Modi, S. _et al._ Understanding the contribution of common childhood illnesses and opportunistic infections to

morbidity and mortality in children living with HIV in resource-limited settings. _AIDS_ 27(02), S159 (2013). Article  PubMed  Google Scholar  * HIV AIDS fact sheet.pdf [Internet].

https://www.who.int/news-room/fact-sheets/detail/hiv-aids. (2021). * Melkamu, M. W. _et al._ Incidence of common opportunistic infections among children living with HIV on ART at Debre

Markos referral hospital, Northwest Ethiopia: A retrospective cohort study. _BMC Infect. Dis._ 20(1), 1–12 (2020). Article  Google Scholar  * Candiani, T. _et al._ Impact of highly active

antiretroviral therapy (HAART) on the incidence of opportunistic infections, hospitalizations and mortality among children and adolescents living with HIV/AIDS in Belo Horizonte, Minas

Gerais State. _Brazil. Cadernos de Saúde Pública_ 23, S414–S423 (2007). Article  PubMed  Google Scholar  * Coelho, L. _et al._ Trends in AIDS-defining opportunistic illnesses incidence over

25 years in Rio de Janeiro, Brazil. _PLoS One_ 9(6), e98666 (2014). Article  ADS  PubMed  PubMed Central  Google Scholar  * Mitiku, H., Weldegebreal, F. & Teklemariam, Z. Magnitude of

opportunistic infections and associated factors in HIV-infected adults on antiretroviral therapy in eastern Ethiopia. _HIV/AIDS_ 7, 137 (2015). Google Scholar  * Dereje, N., Moges, K.,

Nigatu, Y. & Holland, R. Prevalence and predictors of opportunistic infections among HIV positive adults on antiretroviral therapy (On-ART) versus pre-ART In Addis Ababa, Ethiopia: A

comparative cross-sectional study. _HIV/AIDS_ 11, 229 (2019). Google Scholar  * Alarcón, J. O. _et al._ Opportunistic and other infections in children living with HIV in Latin America

compared to a similar cohort in the United States. _AIDS Res. Hum. Retrovir._ 28(3), 282–288 (2012). Article  PubMed  PubMed Central  Google Scholar  * Gona, P. _et al._ Incidence of

opportunistic and other infections in children living with HIV in the HAART era. _JAMA_ 296(3), 292–300 (2006). Article  CAS  PubMed  Google Scholar  * National consolidated guidelines for

comprehensive HIV prevention, care and treatment [Internet]. https://www.afro.who.int/sites/default/files/2019-04/National%20Comprehensive%20HIV%20Care%20%20Guideline%202018.pdf. (2018). *

National Guidelines for HIV and AIDS Treatment and Care in Adolescents and Adults Federal Ministry of Health Abuja–Nigeria [Internet] (2010). * www.who.int/hiv/pub/guidelines/nigeria_art.pdf

(2010). * Chanie, E. S. _et al._ Incidence of advanced opportunistic infection and its predictors among HIV infected children at Debre Tabor referral hospital and university of Gondar

compressive specialised hospitals, Northwest Ethiopia, 2020: A multicenter retrospective follow-up study. _Heliyon_ 7(4), e06745 (2021). Article  PubMed  PubMed Central  Google Scholar  *

Nesheim, S. R. _et al._ Trends in opportunistic infections in the pre–and post–highly active antiretroviral therapy eras among children living with HIV in the perinatal AIDS collaborative

transmission study, 1986–2004. _Pediatrics_ 120(1), 100–109 (2007). Article  PubMed  Google Scholar  * Ylitalo, N. _et al._ Risk factors for opportunistic illnesses in children with human

immunodeficiency virus in the era of highly active antiretroviral therapy. _Arch. Pediatr. Adolesc. Med._ 160(8), 778–787 (2006). Article  PubMed  Google Scholar  * Iacob, S. A., Iacob, D.

G. & Jugulete, G. Improving the adherence to antiretroviral therapy, a difficult but essential task for a successful HIV treatment—clinical points of view and practical considerations.

_Front. Pharmacol._ 8, 831 (2017). Article  PubMed  PubMed Central  Google Scholar  * Luo, B. _et al._ Spectrum of opportunistic infections and risk factors for in-hospital mortality of

admitted AIDS patients in Shanghai. _Medicine_ 95(21), e3802 (2016). Article  PubMed  PubMed Central  Google Scholar  * Ravichandra, K. R., Praharaj, B. R. & Agarwalla, S. Opportunistic

infections in HIV infected children and its correlation with CD4 count. _Int. J. Contemp. Pediatr._ 4(5), 1743–1747 (2017). Article  Google Scholar  * Fonsah, J. Y. _et al._ Adherence to

antiretroviral therapy (ART) in Yaoundé-Cameroon: Association with opportunistic infections, depression, ART regimen and side effects. _PLoS One._ 12(1), e0170893 (2017). Article  PubMed 

PubMed Central  Google Scholar  * Iroezindu, M., Ofondu, E., Hausler, H. & Van Wyk, B. Prevalence and risk factors for opportunistic infections in HIV patients receiving antiretroviral

therapy in a resource-limited setting in Nigeria. _J. AIDs Clin. Res._ 3, 002 (2013). Google Scholar  * Weissberg, D. _et al._ Ten years of antiretroviral therapy: Incidences, patterns and

risk factors of opportunistic infections in an urban Ugandan cohort. _PloS one._ 13(11), e0206796 (2018). Article  PubMed  PubMed Central  Google Scholar  * Masaisa, F., Gahutu, J. B.,

Mukiibi, J., Delanghe, J. & Philippé, J. Anemia in human immunodeficiencyvirus–infected and uninfected women in Rwanda. _Am. J. Trop. Med. Hyg._ 84(3), 456 (2011). Article  PubMed 

PubMed Central  Google Scholar  * Wubneh, C. A. & Belay, G. M. Mortality and its association with CD4 cell count and hemoglobin level among children on antiretroviral therapy in

Ethiopia: A systematic review and meta-analysis. _Trop. Med. Health_ 48(1), 1–11 (2020). Article  Google Scholar  * Kerebeh, G. _et al._ Incidence of anemia and predictors among human

immunodeficiency virus-infected children on antiretroviral therapy at public health institution of Bahir Dar City, Northwest Ethiopia: Multicenter retrospective follows up study. _BMC

Pediatr._ 22(1), 1–5 (2022). Article  Google Scholar  Download references ACKNOWLEDGEMENTS The authors’ deepest gratitude goes to Bahir Dar University, College of Medicine and Health

Sciences, for supporting this study. The authors also acknowledged ART clinic staff, supervisor, data collectors, and card room workers for their cooperation during data collection. FUNDING

No funding was obtained for this study. AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University,

P.O. Box: 272, Debre Tabor, Ethiopia Gashaw Kerebeh, Demewoz Kefale, Ermias Sisay Chanie, Natnael Moges, Dejen Getaneh Feleke & Amare Kassaw * Department of Pediatrics and Child Health

Nursing, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia Aklilu Endalamaw * Department of Adult Health Nursing, College of

Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia Agimasie Tigabu, Berihun Bantie, Abraham Tsedalu Amare & Gebrie Kassaw Yirga * Department of Pediatrics and Child Health

Nursing, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia Teshale Mengesha & Tsegasew Embiale * Department of Nursing, School of Health Sciences,

College of Health Sciences, Woldia University, Woldia, Ethiopia Molla Azmeraw * Department of Emergency Medicine and Critical Care Nursing, College of Health Sciences, Debre Tabor

University, Debre Tabor, Ethiopia Sheganew Fetene * Department of Maternal and Neonatal Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia Wubet

Alebachew Bayih * Department of Psychiatric, School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia Kirubel Shiferaw * Department of Pediatrics and

Child Health Nursing, College of Medicine and Health Sciences, Injibara University, Injibara, Ethiopia Tamiru Alene * School of Public Health, The University of Queensland, Brisbane,

Australia Aklilu Endalamaw Authors * Gashaw Kerebeh View author publications You can also search for this author inPubMed Google Scholar * Demewoz Kefale View author publications You can

also search for this author inPubMed Google Scholar * Ermias Sisay Chanie View author publications You can also search for this author inPubMed Google Scholar * Natnael Moges View author

publications You can also search for this author inPubMed Google Scholar * Dejen Getaneh Feleke View author publications You can also search for this author inPubMed Google Scholar * Amare

Kassaw View author publications You can also search for this author inPubMed Google Scholar * Agimasie Tigabu View author publications You can also search for this author inPubMed Google

Scholar * Berihun Bantie View author publications You can also search for this author inPubMed Google Scholar * Abraham Tsedalu Amare View author publications You can also search for this

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also search for this author inPubMed Google Scholar * Tsegasew Embiale View author publications You can also search for this author inPubMed Google Scholar * Molla Azmeraw View author

publications You can also search for this author inPubMed Google Scholar * Sheganew Fetene View author publications You can also search for this author inPubMed Google Scholar * Wubet

Alebachew Bayih View author publications You can also search for this author inPubMed Google Scholar * Kirubel Shiferaw View author publications You can also search for this author inPubMed 

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author inPubMed Google Scholar CONTRIBUTIONS Author contributions GK, AE, and WA worked on developing the research idea, designing the study, being involved in proposal writing, training and

supervising the data collectors, analyzing and interpreting the results, and preparing the manuscript. AT,GK,SF,TE BB, NM, AT, ES, MA, TM, DG, AK, KE, TA and DK played their role in

critically revising the proposal, participating in its design, analyzing and interpreting the results, and writing the manuscript. All authors were involved in reading and approving the

final manuscript. CORRESPONDING AUTHOR Correspondence to Gashaw Kerebeh. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare that they have no conflict of interests ETHICS APPROVAL

AND INFORMED CONSENT Ethical clearance was obtained from Bahir Dar University, College of Medicine and Health Sciences, Ethical Clearance Review Committee with protocol number 068/2021 and

Institutional Review Board decision number 003, and consent waiver obtained from the Ethics Committee, namely (Bahir Dar University, College of Medicine and Health Sciences Institutional

Review Board). Then, the data was collected after getting a support letter from the administrative bodies of each health institution. This study did not expose children living with HIV to

unnecessary risk due to reviewing their medical records. Confidentiality was kept at all levels of the study, and the data was used only for this study purpose. The study was carried out

according to the Declaration of Helsinki’s relevant guidelines and regulations. ADDITIONAL INFORMATION PUBLISHER'S NOTE Springer Nature remains neutral with regard to jurisdictional

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ABOUT THIS ARTICLE CITE THIS ARTICLE Kerebeh, G., Kefale, D., Chanie, E.S. _et al._ Incidence and predictors of common opportunistic infections among children living with HIV at Bahir Dar

City, Ethiopia. _Sci Rep_ 14, 23403 (2024). https://doi.org/10.1038/s41598-024-72404-0 Download citation * Received: 27 May 2023 * Accepted: 06 September 2024 * Published: 08 October 2024 *

DOI: https://doi.org/10.1038/s41598-024-72404-0 SHARE THIS ARTICLE Anyone you share the following link with will be able to read this content: Get shareable link Sorry, a shareable link is

not currently available for this article. Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative KEYWORDS * Common * Opportunistic * Children * HIV * Ethiopia