Approximately three-quarters of participants achieved ≥80% BPG uptake, and geographic access, longer prophylaxis duration, injection pain, and limited family support were important correlates of lower uptake in this multicentre cross-sectional study of rheumatic heart disease in Ethiopia.
Overall BPG uptake of ≥80% was achieved by 76.3% of participants with RHD in Ethiopia.
Living more than 50 km from an RHD follow-up facility was strongly associated with lower BPG uptake compared with living less than 30 km away.
Longer duration of prophylaxis was progressively associated with lower BPG uptake compared with 12–24 months of treatment.
Frequent injection pain was associated with lower BPG uptake.
Family support was associated with higher BPG uptake.
Male sex was associated with higher BPG uptake compared with female sex.
Increasing age was associated with decreased odds of high BPG uptake.
Achieving ≥80% BPG uptake was associated with substantially lower odds of reported recurrent acute rheumatic fever (ARF) manifestations.
The study used a multicentre facility-based cross-sectional design with logistic regression and exposure-specific confounder adjustment sets.
This research suggests that while about three-quarters of people with rheumatic heart disease (RHD) in Ethiopia received at least 80% of their recommended penicillin injections (called benzathine penicillin G or BPG), a significant proportion still fell short of this target. RHD is a serious heart condition caused by repeated episodes of rheumatic fever, and regular monthly penicillin injections are the standard way to prevent further episodes and worsening heart damage. The study surveyed 400 patients attending three major hospitals in Ethiopia over one year and found that where people live, how long they have been on treatment, pain from injections, and whether they have family support all played important roles in whether they kept up with their injections. Geographic barriers stood out as particularly important: people living more than 50 km from a clinic were about 90% less likely to achieve high uptake compared to those living within 30 km, and people in rural and suburban areas also fared worse than urban residents. Adherence also declined dramatically the longer someone had been on treatment — those on prophylaxis for more than four years were 93% less likely to maintain high uptake compared to those who had been on it for one to two years. Women, older patients, and those experiencing frequent injection pain were also less likely to maintain adequate uptake, while patients with family support were nearly three times more likely to do so. Critically, patients who did maintain high uptake were 75% less likely to report symptoms of recurrent rheumatic fever, reinforcing why consistent treatment matters. This research suggests that making penicillin injections available closer to where patients live (decentralised delivery), finding ways to make injections less painful, and strengthening family and community support systems could all help improve long-term adherence to this life-saving treatment in Ethiopia and similar high-burden settings. The progressive drop-off in adherence over time also highlights the need for sustained engagement strategies, not just at the start of treatment but throughout what can be a decade-long or lifelong course of prophylaxis.
Birru E, Birru Z, Belayneh Y, Alemu M, Oliver J, Kebede Z. (2026). Implications for sustaining secondary prophylaxis for rheumatic heart disease in Ethiopia: Uptake and determinants in a multicentre cross-sectional study.. PLoS neglected tropical diseases. https://doi.org/10.1371/journal.pntd.0014703