Implications for sustaining secondary prophylaxis for rheumatic heart disease in Ethiopia: Uptake and determinants in a multicentre cross-sectional study

BACKGROUND: Rheumatic heart disease (RHD) remains a major public health problem in low- and middle-income countries. Long-term benzathine penicillin G (BPG) secondary prophylaxis prevents recurrent acute rheumatic fever (ARF) and progressive valve damage, but maintaining adequate uptake (i.e., ≥80% dose) remains challenging in high-burden settings. We assessed BPG uptake, factors associated with high uptake, and its association with reported recurrent ARF manifestations among people with RHD in Ethiopia. METHODS: A multicentre facility-based cross-sectional study was conducted among 400 participants with echocardiography-confirmed RHD attending three referral hospitals in Ethiopia between November 2023 and November 2024. Demographic, socioeconomic, geographic, healthcare-service and treatment-related factors associated with high uptake were evaluated using logistic regression (R version 4.6.1) with exposure-specific adjustment sets selected according to plausible confounding relationships. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were reported. RESULTS: Overall, 305/400 participants (76.3%) achieved ≥80% BPG uptake. The odds of high uptake decreased with increasing age (aOR per 10-year increase 0.80, 95% CI 0.69-0.94) and were higher among males than females (aOR 2.64, 95% CI 1.62-4.42). Living >50 km from an RHD follow-up facility was strongly associated with lower uptake compared with living <30 km away (aOR 0.10, 95% CI 0.04-0.22). Rural (aOR 0.28, 95% CI 0.14-0.52) and suburban residence (aOR 0.42, 95% CI 0.19-0.93) were also associated with lower uptake than urban residence. Compared with 12-24 months of prophylaxis, progressively lower uptake was observed with longer treatment duration (2-3 years: aOR 0.26, 95% CI 0.11-0.56; 3-4 years: aOR 0.26, 95% CI 0.10-0.61; > 4 years: aOR 0.07, 95% CI 0.03-0.15). Frequent injection pain was associated with lower uptake (aOR 0.32, 95% CI 0.17-0.59), whereas family support was associated with higher uptake (aOR 2.89, 95% CI 1.24-6.71). BPG uptake ≥80% was associated with substantially lower odds of reported recurrent ARF manifestations (aOR 0.25, 95% CI 0.14-0.44). CONCLUSIONS: Approximately three-quarters of participants achieved ≥80% BPG uptake. Geographic access, longer prophylaxis duration, injection pain, and limited family support were important correlates of lower uptake. Decentralised BPG delivery, improved injection acceptability, and sustained patient and family support may increase long-term secondary prophylaxis uptake in Ethiopia.